The Final Party and a Short Summary

  Today is Saturday, November 15th.  It's 65 degrees here in Guatemala City and 30 degrees in Northampton, ("feels like 23".)  Hmmm, 65, 23, 65, 23 I guess I'll still go home.  There are considerations other than comfort.  Besides, at home there's the wood stove in the living room, the furnace in the basement. In Guatemala, not so much.

  I finally was able to go up on the roof on the 18th floor this morning and take some pictures.  It's a little foggy, but not too bad.  I posted two of the three volcanos of Guatemala.  The largest (closest) one is Pacaya which erupted in 2010 killing three people including a CNN reporter who got too close and was hit by flying rocks.  Pacaya, whose peak is at 8373 meters, erupted in 1965 as well.  Before that it had been quiet since some time in the 1860's.  The other two are Volcán de Agua and Volcán de Fuego. Volcán de Agua which has a height of 3760 meters,  last erupted in 1510.  A resultant mudslide cause a flood, hence the name.  Volcán de Fuego, with a height of 3763 meters, had major eruptions in 2007 and 2012, but is constantly active at a low level.  Smoke and ash rise from the top of the volcano daily.  So that's the mini-volcano lesson and exhausts my knowledge.  It does pique my interest in volcanos, so perhaps that will be my next area to explore.

  Last night we had the team party, a tradition on Op Smile missions.  This one was held in the gardens of Casa Yurrita, a designated historic site, a few miles from our hotel.  It was a beautiful, grand old house, and the gardens had trellises covered with flowering vines.  Cocktails with donated liquor of some sort and crackers and cheese and ceviche were served while the usual goodbye speeches were performed.  We then watched the traditional slide show of candid photos taken by the team photographer.  He did a good job of including all the areas and making sure to have several shots of the local nurses and administrators.

The team party is meant to be fun, but it's also political in that we are encouraged to invite the hospital nurses and administrators, anyone we feel has been helpful.  There were two cleaning women who were wonderful, stripping the beds and making them up again rapidly so we could get the next group of pre-op patients out of the hallway and into their beds.  When Kathy and I invited them to the party, they were obviously bewildered by the invitation, and were non-committal, but came back to us later in the day, smiling and laughing and said they would be there.

What followed was an elaborate if somewhat convoluted speech directed at the two of us.  They had clearly rehearsed it, but it soon devolved into an extemporaneous rant.  It reminded me of my twin six year old grandsons when they are both describing details of the Titanic disaster to me at the same time; they could hardly get their words out.  Through  their graphic use of sign language and rapid-fire Spanish, they made their message clear: "Don't get involved with any Guatemalan men while you are here!  They are no good!  If we see you getting involved with them, we will take a belt and beat you! (laughing.) You need better men.  Wait until you get home to look for men."  Then they ran off and Kathy and I stood there sort of stunned, asking each other if we had really heard them right.  It was a remarkable message from two cleaning women who obviously have not felt respected by the men in their lives. It makes me wonder what they have endured.  They did show up at the party and seemed to have a wonderful time.

  After the slide show we had an elegant dinner of three small slices of a stuffed chicken roll, a small portion of diced, spiced potatoes and a grape tomato cut into three slices.  For me, it was perfect, but the men on the team were incredulous.  The artistic presentation and symmetry of the three slices of both the chicken roll and the tomato - plated "just so"- was lost on them.  They devoured the rolls, drank more mojitos and joked about the giant dessert that must be coming.  Dessert did come but was a tiny demitasse cup of dark chocolate/espresso/rum mousse - again, very elegant.  They all ate it in one scoop of their regular spoon, disdaining the tiny dessert spoon balanced delicately on the rim of the cup.  There was a live band playing wonderful music, so they all got up and soon lost themselves in wild dancing and more liquor.  Being an old lady, I sat with a few other old ladies and enjoyed the spectacle.  At 11:00 the "first bus" left, and even some of the younger set were on it.  All of us leave tomorrow and some have flights as early as 5:00 am.  The later bus leaves the party at 1:00 am and I'm sure many will go from there to an "after party".

  I went through the photos and now the pre and post-op pictures are side by side. There are some remarkable changes.  There is one baby with his fingers in his mouth pre-op and a tube from a syringe full of milk in his mouth post op.  Mom said he always had his fingers in his mouth before surgery and afterwards, he was only happy when he was eating.  I assume he will gradually adapt, and in another couple of weeks he can resume his finger-sucking.  On the bottom of the photos page there are several of kids that I couldn't match; either the pre or a post-op photo is missing.  All in all, we screened 220 children, and operated on 99 this week.  Because some needed more than one thing done, there were 137 procedures.  The dentists saw all the kids at screening and made 22 obturators for babies too young for surgery, did 40 dental restorations and removed 30 unsalvageable teeth.  The maxillofacial surgeon did a maxillary set-back (not the true technical term,) and wiring on a seven year old whose front four upper teeth, and upper jaw (maxilla) protruded so far that he couldn't close his mouth.  His mother said he'd had three prior operations to try to correct the problem, but none was successful.  The maxillofacial surgeon on the team cut through the maxilla and moved it back and wired it in place and he looks wonderful.  The mother requested that there be no photos, so of course I took none, but I do wish I could have shown you all with his eyes covered or something because the surgery was really transformative.

There were three teens who had cartilage grafts from their ears to their noses as the final "nose job" phase of their long surgical roads..  The dental team, which has it's private offices here in the children's hospital runs a free Op Smile clinic year round as well.  They do amazing work making advanced obturators with extensions that go into the nostrils of newborns with clefts to gradually shape the cartilages and help pull the widely cleft lips together before surgery.  This is much closer to what happens in the US and the ultimate results of surgery are much better.

  "If I set aside all the bad, this has been an excellent mission."  The bad is, of course, the kids I saw who but for the place of their birth, could have received medical attention and could now be living normal healthy lives.  It's no different in many countries of the world, and even in the US, there are kids who fall through the cracks of our health system.  But I've said enough on that topic.  Team members came from 10 countries on this mission, US, Guatemala, Honduras, Italy, England, Portugal, Russia, Mexico, Canada and Australia.  Perhaps it's because we all know it's only for ten days, but everyone is very flexible, friendly and willing to do any task that needs doing.  The hospital and Op Smile teams meshed and both sides look forward to working together again.  Maria, the in-country coordinator was able to recruit patients from as far as eight hours away by bus, and will continue to travel around the country to make sure people know they can have surgery free of charge. This was only the fourth mission in Guatemala, so there are certainly many untreated children and adults out there.
  Well, that's the end. Thank you for your interest.  If at any point you would like me to remove your name from my blog list, please send me an email.

  

6th and Last Day of Surgery

  Today was the last day of surgery - only three patients - all teens having cartilage grafts to build up their nasal bridges.  There were two 15 year old girls and one 18 year old boy, and the boy was also having a revision of his lip scar.  None of them wanted photographs taken, and since the volunteers never take any pictures without asking, I didn't take any of these three.  The young man in particular had a remarkable change in his appearance, and once he was awake after anesthesia, he couldn't  stop looking in the mirror.  He was oblivious to the rest of the people in the room - lost in his new look and perhaps fantasizing about the reactions he would experience from his friends.  It was a great way to end the mission.

  While these three patients were having surgery, we all began packing up our areas.  On the ward, we pack any unopened medications, bandages, IV materials, antibiotics and various other supplies, but leave the opened packages as a donation to the hospital.  We also donate extra hospital gowns and arm restraints that are used to keep the kids from pulling out stitches or putting their fingers in their mouths after surgery.  We try to leave the ward as we found it so that the hospital will want to invite us back.  In the case of Hospitál Infantíl, we have found a real partner.  They really enjoyed having us and we loved having the mission here. Not only is it a beautiful facility, the administration and nurses - everyone has been so welcoming and helpful.  This is definitely not always the case.

   I'm still learning about how all this works, but Op Smile pays the hospital that hosts the mission.  I think it varies country by country, but in Guatemala, the hospital is paid $10,000.  For this, they turn over some of their operating rooms - (in this hospital they have four operating rooms, each with two operating tables and they gave us two rooms) - empty out some wards for our patients and supply linens if they can, feed the patients and parents if they can, and supply us with some nursing help.  All of this varies depending on the country.  On my trip to Bhubaneswar, India, the hospital had only a few sheets and no cribs, and the food for the parents was so sketchy that Op Smile had to supplement it.  In contrast, the hospital in Guwahati, India provided wonderful meals that made us want to trade in our box lunches.  When the mission is over, the hospital receives quite a lot of stuff in the form of drugs and supplies as any open package can't be packed up for the next mission.  Even with all of that, some hospitals really feel invaded.  The last time I was in Guatemala City for a mission, it was held at the military hospital.  The top brass decided to host the mission but the surgeons and nursing personnel were definitely not on board.  Using candy and cake and lots of friendly overtures, the pre/post nurses and I managed to win over the ward nurses by the end of the mission, but the OR remained tense.  The outcome was that the military hospital  said they'd host again but only if the fee was raised to $30,000.  So, here we are at the lovely Hospitál Infantíl, a much better choice.

  I have four quick anecdotes to relate and then I'm off to the final dinner. I'll write a wrap up tomorrow morning and perhaps have a few more photos.  I've been trying to get photos from the roof where I'm told one can see all three volcanos one can see on clear days.  The problem has been fog or darkness or no time each morning, but tomorrow at least two of the three won't interfere as I won't be getting up early to go to the hospital.

Ok, anecdote number one:  Oscar, one of the surgeons from Guatemala, a really great, elegant, gentle older man who is the team leader for the surgeons, started todays's wrap-up at the morning meeting by saying, in Spanish, "Leaving out all the bad, everything in the mission has gone quite well."  The coordinator looked startled but translated it to English.  Oscar kept a straight face for about 15 seconds while the team members looked around at each other silently, wondering what bad things he meant, and then he burst out laughing, practically falling over, clapping his hands and chanting, "I got you all," over and over.  It was especially effective because he is so soft spoken and polite in a sort of old fashioned European way.  One would never expect Oscar to do something like that.  He clearly had planned it and was so gleeful about carrying it off.

  Anecdote number two:  Every morning the surgeons make rounds, taking out tongue stitches. (a brief  diversion here: at the end of surgery for a palate repair, the surgeon puts a stitch through the tongue and brings the suture out onto the cheek and tapes it there.  The purpose of the tongue stitch is to have something to grab onto to pull the tongue forward if the child begins to bleed and you need to get the tongue out of the airway while you put pressure on the palate.  If there's no stitch, you may have to use a hemostat (clamp) to grab the tongue which would be quite painful.) Taking the stitch out is painless as it requires just a clip of the thread which then slides out.  This morning, they entered the first room en masse as usual, and the one year old in the first bed, took one look and swung his little arm across his body to point directly at the child in the next bed.  He didn't cry or cringe against his father, he just stared right at the closest surgeon and said, silently, with very eloquent sign language, "It's him you want, not me!"  Yay babies!

  Anecdote number three:  One of the Guatemalan surgeons is young and tall and handsome; looks like an ex football player, and all the young nurses swoon whenever he comes to the ward.  Turns out he's happily married with two little boys, very polite and not flirtatious, unlike some of the older surgeons with less movie star qualities.  This morning, after he took out the tongue stitch on a seven year old boy, he took a flashlight and asked the boy to open his mouth so he could check the palate.  He looked for awhile and then sat down on a chair next to the bed.  He asked the boy how old he was and after the boy told him, he gave a big sigh.  Then  he said to the boy, "look in my eyes so you can see that I'm serious while I talk to you.  You're seven now so you are old enough to be responsible for your own teeth."  He then talked to the boy for five full minutes about brushing his teeth twice a day, how to do it, why he should do it, what foods could make his teeth get holes in them and what foods might make his teeth stronger.  The boy was mesmerized and never took his eyes off the surgeon.  At the end, the surgeon said to him, "remember, you only have to brush the teeth you want to keep."  I was very impressed.

  Anecdote number four:  In Latin America, people greet each other with hugs and kisses.  Strangers get a handshake, but if there is any chance you have met before or any connection at all, there is a full body hug and kisses on one or both cheeks.  Small children are encouraged to give kisses in greeting and on leaving and they learn this very young.  Today, as yesterday's patients were leaving, I was kneeling on the floor doing a pre-op check on one of the teens who was having surgery today.  A 15 month old who had had a palate repair came toddling up (at her mother's urging,) leaned in and hugged my arm and kissed my cheek.  She then toddled around to the other side to repeat the hug and kiss on the other side.  Manners 101 in Guatemala!
Off the the party - more tomorrow.

Fifth Day of Surgery and another dose of the way it is

We almost managed to get away with just five surgical days, but there were too many cases and toward the end of the afternoon it became clear that some would need to wait until tomorrow.  In the end, only three are on tomorrow's schedule, though it's possible another one or two of the standbys who live locally might be added.  They are all shorter cases, lip scar revisions or follow-up nose surgery, so none will be longer than an hour or two, and all will be able to go home by the afternoon.  We'll still need to go in early to discharge today's patients and to have enough time to pack up all the equipment.

I've posted a few more photos.  There are some babies with tubes in their noses. One of the young surgeons from Guatemala uses them to support and shape the nasal cartilages.  The parents can take them out to clean them an then put them back in.  The babies wear them for two to four months and the surgeon says they make a big difference in how the noses look.  I'll try to match up the pre and post op photos a bit more.  There are also some photos of kids playing games while they wait for surgery.  The Child Life team and volunteers have been great at keeping the kids busy and distracting those who are scared.  Finally, there are photos of Kathy, (the nurse who wore princess and Turtle costumes and today was in a Superman costume,) and me kneeling in the hallway doing pre-op checks.  It seems on all missions the parents and kids are in chairs and the nurse and I are on our knees on the floor.

There were some challenges today on the post-op ward.  One 14 month old who had had palate surgery came back very sedated and had an oxygen saturation of 70, normal being around 95-98%.  She'd been wild in the recovery room so they had given her a couple of doses of a pain medication that can cause sedation.  Though she was OK when she left recovery, she became more sedated when she hit the ward.  We kept her for about an hour with oxygen in our "crash bed," a bed we always keep by the nurses' station that's equipped for emergencies, but she was still out cold, so we took her back to the recovery room and let them keep her for awhile till she woke up.

A little later, another palate patient started to bleed.  The palate is very vascular, and a bit of bleeding is common.  We put pressure on the palate, rinse with ice water and even use tea bags, and generally the bleeding stops.  This time, it continued through all our tricks, so we sent the patient back and the surgeon sewed a gauze pack into the palate.  About an hour later, the father came to the desk and asked the nurse to come check his son. He wanted to know if the breathing was supposed to sound like it was.  The baby was lying on his back making horrible strangling noises.  He was struggling to breath around the pack which was now soaked with blood and swollen to three times it's starting size, filling his airway.  The nurse sat the baby up, and the baby took in a huge gasping breath as the pack shifted forward out of his throat.  She kept him that way while I called the surgeon who came down to the ward, cut the sutures and pulled out the pack.  The pressure of the giant pack had stopped the bleeding, so all was well. Heh.

Yesterday there was a four year old who was supposed to have his palate done, but the dentists were also planning to do some fillings.  When they got him under anesthesia and could do a good exam, they found that he had multiple abscessed teeth and they ended up having to pull 16 teeth!! They cancelled his palate surgery and put him on high dose Augmentin and sent the family to the shelter (housing we have at all missions for families from far away,) for a week to follow along and make sure he was getting better.  Today he returned to the ward because the parents reported that he won't take the antibiotic because it tastes bad.  He's feverish and miserable, of course, but I expect our nurses will get the antibiotic into him.

Though not quite as devastating as yesterday, I had another "the way it is" experience today.  I was asked by Monica, one of the in-country coordinators if I would speak with the director of finances of the hospital.  He has a friend who had come to see him today with her 14 year old daughter who has PKU (phenylketonuria.) PKU is a metabolic disorder where there is a problem metabolizing phenylalanine.  It builds up in the blood and tissues and causes damage to the brain, among other things.  Though not common, before newborn screening for PKU became routine, it used to be an uncommon but significant cause of mental retardation in the US.  Once PKU is diagnosed, the buildup of phenylalanine and resultant retardation can be prevented by giving the baby a special low phenylalanine formula and later supplementing with a very selective diet.  Unfortunately, Guatemala has no screening program and no source of the special formula.  I went to the financial director's office and met the girl and her mother.  If it weren't so sad, I might have seen it as a rare opportunity to see a patient with untreated PKU; there are physical characteristics that I had never seen before.  However, after a brief introduction by the financial director, I mainly listened as the mother told her story.

 Her daughter seemed normal at birth but fairly early she suspected something was wrong because she wasn't developing like her older sister.  She took her to several physicians who initially reassured her and eventually told her that her daughter had autism.  She accepted it for awhile, but when she noticed that her daughter had a slightly musty smell and that she had lighter hair and eyes than her sister, she started reading in the library and later online.  Once she suspected a metabolic disorder, she tried to find a doctor who specialized in that area, but there isn't such a specialty in Guatemala.  On her own, she narrowed it down to PKU and a couple of other things and finally found a doctor who would run the tests.  Her daughter was 10 years old when she was finally diagnosed with PKU.  By then, she had sustained significant brain damage and functions like a very young child.  The mother is an expert on PKU.  She has written to Abbot Labs trying to get their low phenylalanine formula for her daughter to no avail.  She wanted to see me to see if I could facilitate a consultation between her doctor at the Hospitál Infantíl and a specialist in the US and possibly assist in getting Abbot to donate formula.

In fact I, along with Operation Smile and the contacts they have with Abbot who supplies anesthetic for them, may be able to do all these things for this mother and child, and the mother will be able to stop doing everything herself with no support.  If so, her child's damage will likely stop progressing, but it won't reverse.  Unfortunately, the crucial time for treating PKU is the first year, and this girl has had 14 years of very high levels of phenylalanine.  Unfortunately, she's not alone.  Maritsa, the local pediatrician told me there is no screening and no treatment for PKU in Guatemala.

Fourth day of Surgery and thoughts on the way things are

  Today was the fourth day of surgery and instead of getting better, the morning has deteriorated into one of those great ideas gone wrong situations.  The pre-op team was supposed to leave at 6:30 and the rest at 6:45, but the whole operating room team - nurses and techs and the Child Life group who help the kids get through surgery, do pre-op teaching, comfort parents, etc felt they should go early too.  As you might imagine, it was impossible for that many people to get on the bus on time.  We ended up leaving at 6:40, just late enough to get stuck in the morning traffic.  The second bus left at 6:45 so we had about 5 minutes to prep the first group for the OR before the surgeons arrived on the ward to do their rounds.  I have to go around with them as they all have things to say about what they want added or subtracted from the standard discharge orders. I have all the discharge orders pre-written and ready to sign, an usually they're fine. However,  there are always a few that need to be revamped.  All of them must be signed before I can return to the pre-op patients because the kids need to leave so beds can be stripped and re-made for the next round of patients.  This morning, because we were late, I didn't get back to the pre-op kids until just after 8:00, and Rosa, the nursing director had sent the kids to the playroom and the mothers to the parent dining room for breakfast.  Rosa is wonderful in almost every way, and she didn't get to be director of nursing by being wishy washy.  Breakfast for the parents is at 8:00, and is not delayed just because the doctors get behind.

  So, enough griping.  The parents got fed, the kids got prepped and my blood pressure gradually came down.  You'll notice from the photos that all the kids wear caps to the OR. These have long ribbons on them and the parents like to wrap these around the child's neck and tie them in a knot.  I find myself shuddering a lot and occasionally sneaking the knot open as I pretend to soothingly pat a child's head.  I'll organize the photos when I'm not so rushed, but two kids in particular stand out. One is a child with a cleft lip and lobster claw deformities of the hands and feet.  He also has very sparse hair on his head.  He's 7 months old and has a 4 year old brother with the same syndrome.  The hair gets thicker as they get older.  You can probably pick him out by the hair.  He has a very lovely result.  The other one will have to wait until tomorrow as I still don't have photos.  He's about seven and his front top four teeth stick out so far he can't close his mouth.  One of the plastic surgeons is also a maxillofacial surgeon and he fractured the maxilla and moved it back and wired it in place.  He and the plastic surgeon then closed the lip.  The result is phenomenal, but the child is having a slow recovery.  We've been using stronger pain medications and today he was sitting up and even playing a bit after spending the first 24 hours after surgery alternately crying and being knocked out by pain meds.  I hope to get a post-op followup tomorrow.

  A couple of babies have plastic tubes in their nostrils acting as splints to maintain a rounded position as the cartilage heals.  The tubes can be removed for cleaning, and the babies don't seem to mind them.   You'll see some in the photos.  There were some cancellations due to illness, so tomorrow might be the last day of surgery with Friday morning's patients moved to tomorrow.  We'll see.

  This was a very difficult day for me.  Mid morning I was called emergently up to the dental clinic by a student and technician who were seeing a baby for an obturator recheck appointment.  They said the baby was blue and breathing fast.  When I got there, I found a very blue baby with and oxygen level of 61(normal around 98-100,) and a very rapid heart rate.  As I examined her, she laughed and smiled and grabbed at my stethoscope, trying to eat the tubing like most one year olds do.  After a bit it was clear that this was the baby I had seen at screening, the one with only one ventricle.  The mother confirmed this saying that the cardiologist had told her there was nothing they could do for her baby.  The mother is quite young and was there with her own mother as well.  After reassuring the dental student and technician and talking with the mother a bit and making sure she would see the nutritionist this week, I went back to the ward.  For some reason, seeing this little girl was just devastating for me today.  Any big children's hospital could choose to take her on and swallow the cost of her heart transplant, the only thing that could save her.  It won't happen because the business people don't think in terms of one baby.  They think in terms of actual dollars and would add it up and it would be prohibitive.  Also, they would think of it being a precedent, the flood of people who would hear about it and send them lists of needy kids, and on and on.  Actually, a hospital could do it with the doctors and staff donating their time and then just not counting all the little beans.  It wouldn't affect the budget or bottom line at all.  Or, one of the many extremely wealthy people in the US or other well off countries could easily foot a bill for this child.  Or some big donor could do it with some stashed stock options.

  I know it's not realistic to think this way and there are tragedies playing out all over the world.  I'm also aware that this little girl is just one of thousands in the same state of terrible health and that one can't help them all.  The thing is, someone could help this one child, but it won't happen because that's the way things are.  Someone or some institution could quietly save her life without turning the deed into a media circus and therefore initiating an avalanche of calls for help.   It won't happen because no one who could help has a vested interest in helping.
So, that's my rant for today.  Tomorrow I'll be upbeat!

Third Surgical Day

This will be a very short entry written early on Wednesday morning.  Yesterday, the whole team left the hospital earlier.  The small pre-op group, consisting of two nurses and me plus the OR techs and nurses still left at 6:30 but the rest of the team left at 6:45 instead of 7:00.  That made just enough difference that they avoided the traffic jam that happens in Guatemala City 15 minutes later.  If I were someone who was fascinated by cities or traffic flow, (which I'm not,) I could probably do a great research project on the traffic patterns of big cities around the world and how one or two minutes makes a difference of 30 or 40 minutes in commute times.  Perhaps it would be published in a prestigious journal and win me the Nobel prize in Urban Development.  Of course anyone who commutes already knows this stuff and has their timing worked out precisely.

Here I am rambling when time is short.  So, the earlier departure time worked and the 15 minute lead time was fine.   By the last surgical day, we'll have it all worked out. We were out of the hospital by 7:30 last night, and I'll write about some patients tonight, but for now I just wanted to share the reason for not writing yesterday.  Instead of returning to the hotel and having a rare early evening, we went directly to a huge IHOP restaurant. IHOP in Guatemala is a big supporter of Operation Smile, and had offered to host a dinner for the team.  In addition, they put three burger combinations on the menu, the proceeds of which would go 100% to Op Smile.  These were, cheeseburger with fries, barbecue bacon cheddar burger with fries and mushroom bacon with cheddar burger with fries.  There was no real pressure to order these items except the obvious good natured ribbing of those who decided to get pancakes (only three out of about 50.)  Some people ordered the burgers which went for the equivalent of $8.00 and pancakes and donated the burger to a big eater at the table.  As I'm not really a beef-eater, I ordered the mushroom cheddar burger and ate the bun and fries and donated the rest to a very grateful OR tech across the table.  Despite being kept out late, the team took the whole fund-raising deal with great good humor and multiple toasts to our guests from Johnson and Johnson who were with us for their last night.  They gave speeches about how moving the experience had been for them and other people gave toasts to the director of the hospital who was obviously very pleased to be the center of attention at such a large gathering.  Though we didn't get back to the hotel till 10:00, it was an evening well-spent and reminded me of how much Op Smile means to the donors and supporters, and of how important it is to support them.

I put up only 8 new photos, a few of patients, one of Steely-eyed Dan on the bus, scanning for bad guys and one of the logo of Escorpion Group on their truck.  I feel very safe.  More tomorrow.

What I love about this mission - and - second day of surgery

Today is Monday, the 10th of November, and the second day of surgery.  The ward nurses and I left the hotel at 6:30, a half hour before the rest of the team, so that we could get the first eight patients  ready for the OR.  I've learned that it's essential for the pre-op team to go early because once the surgeons have arrived, the pediatrician needs to go around the ward with them while they do discharge rounds so that discharge orders, which the pediatrician writes, will include their wishes.  They also have questions about how the post op day and night have gone and look to the pediatrician to give a report.  After they do their rounds, they head off to the OR and almost immediately call for the first two rows of patients.  Without advance prep time, it's impossible to have the kids ready, and the whole day is delayed.

 This morning, the main team left the hotel at 7:00 and got bogged down in the morning rush hour traffic.  The surgery and anesthesia team leaders got together and decided the whole team should come at 6:30 to avoid the traffic.  Since the hotel starts serving breakfast at 6:00 and won't accommodate any early diners, that would mean that the pre-op team would have no prep time.  I had to do some fast talking and be uncomfortably pushy, but a compromise was reached! The pre-op team will leave at 6:30 and the rest of the team at 6:45.  Maybe we'll let a bit of air out of the tires on their bus before we go.

By mid-morning I realized that this is a beautifully run mission, and there are several things that I love about it.  First, the Hospitál Infantíl is very happy to have us here and everyone is friendly.  The chief nurse is always around and if we ask for something, she provides it at once.  The ward nurse, Sandra has worked 24 hours on, 12 hours off for the past 21 years and is one of the more cheerful people I've ever met.  She greets us all with a big hug and a kiss on each cheek each morning and can jolly the fussiest kid into taking some juice.  The pediatrician, Maritsa has been here 20 years and facilitates medical needs such as labs, medications, appointments and referrals.  She's about five feet tall and wears 4 inch heels and beautiful makeup.  Kathy, the pre-op nurse who dressed like a princess for screening and in wild colors yesterday, wore a Teenage Mutant Ninja Turtles outfit today, complete with cape.  She's done 30-40 missions and has all the details set.  On many missions, it's my job to make sure all the small but crucial things happen. These can include making sure all the kids have had their labs done and that the labs are normal, all the charts have the needed pre-op forms, the "code sheet" which has all the code drugs pre-calculated per the patient's weight has the right weight, the kids are truly NPO, etc.  On this mission, all those things happen automatically because Kathy has "systems" she follows to get them done without a hassle.  She's crazy on the outside but a bit OCD - in a good way.  The other Kathy, who works in the children's hospital in Denver, also wears colorful scrubs, and today wore her Ninja Turtle scrubs as this was Turtle Day (see photos for coordinating outfit picture. )

Other things I love about this mission are:  Real toilets complete with seats and toilet paper, fruit for snacks at the hospital instead of chips and stale cookies, really nice sheets and quilts on the patient beds, a lunchroom and three meals a day provided for the patient's parents, volunteers who play with the patients while the parents eat, a really great team that doesn't have any members with "issues."

What I don't love about "developing," poor countries: the inequality with which people can access medical care.  This morning around 11:00 the team dentist asked me to come upstairs to the clinic to see a two month old who was in for a fitting of an obturator and had a rash.  Babies who have cleft palates have a hard time getting a seal to suck, so the dentist can make an obturator - sort of like a retainer - to seal off the connection between the mouth and nose and create a seal.  He had seen the baby 10 days earlier and made and obturator and she was returning for a recheck.  The baby was dressed in five layers of shirts and pants and one piece pajamas, and when she was finally undressed, I was shocked to see how emaciated she was.  She had weighed six pounds at birth and now weighs five pounds.  The mom said she had been drinking formula with a special bottle for babies with clefts and that she tried to feed her every three hours but the baby got tired easily.  I asked to watch the baby feed, and it was heartbreaking.  She was obviously ravenous, but couldn't make a seal on the bottle so she couldn't suck effectively.  After about two minutes of effort, she gave up and drifted off to sleep.  The mom is poor and the baby hasn't seen a pediatrician.  She was given the special feeder at an intake visit by an Operation Smile outreach worker, but didn't realize she could receive services free, so didn't return.  For some reason, she knew the dental part was free, so she came for that.  The hospital pediatrician came through again and got the nutritionist to see her for free, and now the Op Smile nutritionist will take over, but I couldn't help feeling outraged that this baby would not be getting the care she needs.  I just kept thinking, she's a person too.  Her mother is poor and therefore she starves while surrounded by excess. It's not right.  I know that's naive and that's just the way things are in much of the world, but there was something about watching this tiny person trying so hard to eat that did me in.

The second day of surgery was generally smooth.  I took a few post-op pictures and tried to do some pairing and some new pre-ops and post-ops that I'll try to improve on tomorrow.  There was one difficult patient right at the end of the day that kept us all a bit late.  An 11 month old had her palate repaired and then had some bleeding.  Controlling the bleeding meant extra fluids and then she had trouble with her oxygen saturation and became a bit overloaded with fluids.  Eventually all was resolved, but it turns out she likely has an kidney problem that caused the fluid overload problems.  Tomorrow I'll see if I can sort it out, and if there is a problem, find out if she can find treatment here.

Finally, two sort of funny anecdotes.  Because of the way the scheduling went this morning, we had four patients sitting in the hallway for awhile before they could move into the Child Life area to wait for the operating room  Since yesterday's patients had been discharged, we let these four patients' mothers go and pick a bed for their child so they could get out of the hall.  We didn't consider the consequence which was that every other mother then wanted to rush through the wards and choose a bed.  If all beds were equal, this would have been fine, but 11 of the 22 beds are cribs and we have to put the infants in those. Also, there are 3 beds in tiny private rooms that we try to save for the teens or young adults instead of toddlers or school aged kids.  Squabbles erupted and we had to move some five year olds out of cribs.  For tomorrow, we will pre-choose all the beds. Heh!

Since the political situation is a bit iffy in Guatemala right now, Op Smile has engaged a local group to provide security for the team. A couple of the pre/post nurses and I got a look at the security truck that discretely follows us.  It's from the Scorpion Group and has big scary looking scorpions on the sides. Creepy.
More tomorrow.

First Day of Surgery

This is my 13th mission with Operation Smile and therefore my 13th "first day of surgery."  Usually the first day is fairly chaotic as everyone is adjusting to working in a different hospital, different operating rooms, and many languages.  In addition, there are many, many things that must be done right to assure the safety of the children. Lab work, drug dosages, allergies, previous reactions to anesthetics, screening for underlying illnesses - all in just a couple of days.  What's really remarkable to me is how the surgeons and anesthesiologists come together with OR nurses and technicians and spend five or six days operating all day harmoniously.

I think the norm is for a surgeon to work with a team that he or she knows and works with all the time.  They can all anticipate each other's moves and work like parts of a well-oiled machine.  In contrast, on an Op Smile mission, the surgeons and anesthesiologists have to set aside any personal preferences and be extremely flexible about how the OR nurses and techs do things.  Most seem to do this in great good humor, perhaps because they are dedicated to the cause.

Anyway, that was a long way to say that I now have some comparison experiences, and today was an extremely smooth and enjoyable first day of surgery.  It helps that many on this team have worked together on missions before, but there were also no major glitches or complications to slow things down.  Mid morning, Maritsa, the Guatemalan pediatrician who is working with us asked me to see a six month old baby who had been brought over by ambulance from the government hospital.  The baby had bronchiolitis, a respiratory virus, and needed to go on a ventilator, and they had been unable to intubate the baby.  They had tried several times and then had brought the baby over in an ambulance, using a bag and mask to help the baby breathe.  Maritsa had tried once and then asked me to try.  However, after a quick look, I decided that the wiser course of action was for me to tend to the patients in our recovery room and have Igor, our Russian pediatric intensivist who is also a pediatric anesthesiologist, intubate the 6 month old.  Igor gathered up some drugs and gear and went down to the ER, sedated the baby and put in a tube in about two seconds.  The baby was then sent back to the government hospital because the family had no money to pay for care at the pediatric hospital. Maritsa was very unhappy about the transfer back but said this was the policy of private hospitals in Guatemala.  Igor, in describing the intubation said, "How silly to try to intubate awake and kicking baby who tries to grab tube!  I just knock him out and slip it in, and Finished!"

We had several young babies with cleft lips today and I put up some pre-photos and will get post ones tomorrow.  They have wonderful results which will make such a difference for them.  Generally, once they are drinking well, we remove the IV's, and one eight month old girl was ready about three hours after she returned from the OR.  I told the mother I'd remove it as soon as she woke up, and to call me.  I didn't hear from the mother for a couple of hours. and then the baby's 5 year old sister came to the desk where I was charting and put her hands on her hips and said, "No one has come to take out my baby sister's IV!!" So, I went with her to remove the IV, and while I was removing tape from the baby's arm, the older sister began flipping my hair up with her fingers.  She then leaned towards her mother and in a loud stage whisper said, "Qué pelo loco!" (what crazy hair!) Heh - observant little thing.  Meanwhile, the 8 month old kept up a steady crying chant of, "a casa, a casa, a casa," (go home, go home, go home.)

Kathy, the nurse who dressed in the princess dress for screening had on another wild outfit today (see photos.)  She's great with the kids, letting them help take vital signs on each other and fixing the girls' hair so it fits under the OR caps they require here. (see photos.) I also posted some photos of the wards.  The ones with the bunkbeds are of the pre-op wards where kids stay the night before surgery. The others are of the post-op area.  There's also a photo of Sharon, another nurse, juggling, and some of the young sibling I wrote about above, standing in awe and then trying it herself.  She worked for over an hour and was finally able to juggle two balls for a short time.  There are also photos of some the volunteer girls from the American School who come and entertain the kids, and one of Kathy, Maritsa and me.  Finally, there are some of the "Popemobile" with John Paul II's picture in the front. When he was Pope, he came to Guatemala three times and rode in this vehicle, and now it is parked permanently at the hospital.  It is carefully covered each night and treated as a relic since he was made a saint.
That's it for today. Tomorrow more surgery.

Team Day

Today the team went to Antigua for team day, designed to promote team bonding before the intense week of surgery.  I'd been there two or three times before, but it's an interesting place to visit if you don't mind the crowds.  There is also the unending parade of vendors offering scarves, jewelry, flutes, blankets and drums.  Small boys and girls carry trays of candy and gum and circle around you chanting, "chicle, gum, dulce, candy, carefully avoiding eye contact where they might have to acknowledge that you've declined.  After a very nice lunch in the outdoor courtyard of a hotel restaurant sponsored by Pepsi, a big supporter of Operation Smile in Guatemala, we wandered some more before returning to the busses for the trip back to Guatemala City.  A group of about eight of us rode in a smaller van as we had to go to the hospital to organize tomorrow's charts and make sure the lab results were all in and held no surprises.  The ward is really nice with great beds, clean bathrooms, and nurses who are happy to have us on their ward.  My apologies for the dearth of photos - I promise they will appear tomorrow.

The 45 minute drive back took over two hours due to weekend traffic.  Since I was riding in the van instead of the larger bus, and was in it for a long time, I took notice of a man who has been riding with us since we arrived.  He's tall, clean-shaven and well-built, dresses in a black suit and tie and has very well-shined shoes.  Turns out he's our security guard and James, one of our project coordinators refers to him as "Steely-eyed Dan."  Two years ago when I was on an Op Smile mission in Guatemala, we had a soldier who looked about 12 years old standing in the doorway of our bus.  He  had a rifle slung over his shoulder, and looked for all the world like someone's kid brother.  Last year they apparently had a more convincing soldier on the bus, and people complained, so this year, it's Dan.  We also have a "follow truck" with armed guys.  All of this is done at the request of the Op Smile Foundation in Virginia, perhaps because of the press coverage in the US, or maybe because Guatemala is fairly high on the most dangerous countries list.  I always feel safe here, but I'm not out wandering the streets.  I generally leave the hotel at 6:30am and return from the hospital between 8:30 and 10:00pm, so my "out and about" time in the danger zone is pretty limited.

Tomorrow the action starts with the first day of surgery, so I'll stop here and get some sleep. Just one observation and a quick story.  I really like this team and it's been fun catching up with some of the people I've known from prior missions.  However, I was wandering in the shops with three women, and two of them were haggling prices just "for the fun of it."  I know it's supposed to be "part of the fun," and that the prices are raised for the tourist trade to take the haggling into account, but it bugs me.  The artisans are charging so little for their wares in the first place that it seems wrong to try to pay less just as a game.

The quick story is that yesterday, Alessia, the Italian anesthesiologist left screening to go set up the OR.  She found a box with endotracheal tubes - used to put in the trachea of unconscious patients to breath for them - but they were all big adult size.  After searching for a long time, she came back to screening and asked the surgeons and other anesthesiologists if they knew where the smaller tubes were.  Everyone was busy and distracted and gave her quick shakes of the head or negative responses.  After further searching through all the boxes, she still couldn't find them.  She returned and asked more forcefully and got a bit more response, but still no real interest.  Everyone was sure they were around somewhere.  Then at breakfast this morning, she came into the dining room and yelled, " OK! EVERYBODY STOP CHEWING, STOP TALKING, AND LISTEN TO ME! THERE ARE NO ET TUBES FOR CHILDREN HERE!!" and then walked out.  After a short silence, the anesthesiologists left as a group to search all the boxes again and finally found them in a miss-marked box, so they all went on team day happy.
Tomorrow - first surgical day.

Second Day of Screening

Today was a much busier day as it was a combination follow-up clinic day and surgical screening day.  About a third of the kids we saw were there for a follow-up on the operations they had done a year ago.  A few turned out to need minor revisions and were put on the schedule, but most were fine.  The other two thirds were there to be screened for surgery this week.  It made for a very hectic day, but it was the first time I've had a chance to see the longer term post-op results from a mission.  The kids looked great! Generally, when I leave, though the changes in the children's faces are dramatic, there is swelling and the stitches are in place and often there is tape obscuring part of the lip or nose.  Also, the kids are generally in pain and unhappy.  It was lovely to see smiling happy kids with minimal scars chattering away in the hall.  It was also really nice for the parents of the babies who were there for their first evaluations to see the results first hand.

We started today with a Mass that was arranged by the hospital in our honor.  Attendance was optional as Op Smile is not a religion-based organization, but I think nearly the whole team attended out of respect for the hospital administration.  I've only been to Catholic Mass a couple of times, for first communion of a nephew's daughter and for a friend's wedding.  They were fairly formal affairs and my main memory of them is that they were long.  Although this one followed the usual format, there were a few things about it that made it very different for me.  The first was that they had a "Moment of Peace" similar to what I've experienced in Protestant churches where everyone turns and greets the people around them and offers wishes for peace.  The next was that the priest walked all around the conference room where the mass was held, dipping an evergreen branch in a silver vessel of ? holy water and flicking on us while repeating a phrase about anointing.  If he missed anyone in a row, he would stop and grin and dip the branch and fling more water to be sure everyone was anointed.  It was clear he was having a good time as well as performing the ritual.  Next, I was sitting beside Alessia, the anesthesiologist from Italy.  She said that she loves to go to Mass in Spanish speaking countries because when the priest talks about the "lamb of God," he uses the word, "cordero" for lamb.  In Italian, there are apparently two words for lamb, one for the animal and one for lamb you eat, which is cordero like the Spanish.  So when the priest said "Cordero de Dios," Alessia started smacking her lips and saying, "Mmmm, cordero," under her breath.

The real highlight of the Mass, however was the priest's homily.  He spoke about trying to really think about what an ideal world would be like if all obstacles were gone.  Ask yourself what your dream world would be.  He said that of course, some might right away think of being a basketball star or a billionaire, but that those were fleeting.  Instead, he meant to try to imagine what the world could be like. He imagines a world with no hunger or war where everyone treats one another with kindness and respect.  Then, he said, each morning when you get up, try to live just that day in the image of your dream world.  When he's downtown and there are beggars or people at intersections trying to sell him trinkets, he always gives a little and always greets them.  He said he knows that giving a few cents to a person here and there doesn't really affect the world in any great way, but it is consistent with moving toward his envisioned world.  He tries to make each action he takes each day reflect his dream, and feels if more people did this, the world would move toward peace..
I found myself captivated by what he was saying.  There are many times when I second guess what I'm doing, particularly when I go to a village in Guatemala and give a child a month's worth of vitamins or treat his current pneumonia.  Neither action will have much effect on his ultimate health, nor any on the health of his community.  The community gardens we're facilitating will have a sustainable impact on the people whose villages receive them, but there are hundreds of villages whose members will continue to go hungry. The priest's words, however made me realize that even small actions have meaning, even if you only help a handful of people.  Enough philosophizing.
A volunteer from Canada presented the priest with a candle that has been passed from church to church on medical missions, starting at a Russian church. There's a photo in Picasa of the priest with the volunteer.

I also posted some photos of the surgical scheduling.  I have only been in on that process one other time as it's usually done by the clinical coordinator and the surgical and anesthesia team leaders.  This time it just turned out that all the surgeons and three anesthesiologists and I were together in a room when the clinical coordinator came in with the scheduling boards and charts, and we all did it together.  There are some unwritten guidelines - try to get the babies on the tables first so they don't have to go without eating so long, balance lips and palates so the surgeons don't get exhausted, alternated longer and shorter cases, etc.  This time, there were also some controversial cases that we had to all agree on if they were to have surgery.  One was a 17month old boy who weighs only 8 pounds. He has a syndrome of some sort with some hand and foot deformities and mild hydrocephalus, and a cleft lip and palate.  He doesn't walk or talk and has difficulty eating due to his cleft lip.  The family lives in a very remote village 8 hours away by bus and saved up money since he was born to come today.  Some people didn't want to do his surgery as he looks frail and has all these other problems. One of the anesthesiologists and I felt strongly that he should have it in order to be able to eat and to get the family accepted back into the village.  We eventually won the rest of them over and he's on the schedule.  I was very impressed with how thoughtful the discussion was around scheduling the patients. I posted a couple of photos on Picasa of that process as well.

 There are also some of the Child Life people playing with kids outside while they wait to be called for registration.  It's a very long day for the kids and their families, and the Child Life team members do a great job playing, supporting parents, demonstrating masks, IV's and other OR paraphernalia and just easing the kids' way in general.  I put up a photo of a child and Mom in traditional dress and then the same couple with Igor, the pediatric intensivist from Russia. And finally, a couple of photos of kids having their pre-op photos.  They get fairly precise photos done before, during and after surgery to track their progress.  The younger kids hate it as they have to be held in precise positions.
Well, I'm drifting so I'll stop now. Tomorrow is team day at Antigua and then Sunday, the surgery begins.  I decided to wait on pre and post op photos until the surgical days to try to keep order more easily.

First Screening Day

Most Operation Smile missions have one screening day during which the team sees 200 to 250 patients in order to find 100 to 130 who are eligible for surgery.  When there are two screening days scheduled, you know that it is a really big mission.  This is just the fourth Operation Smile mission in Guatemala, so they are still playing “catch-up,” trying to treat a backlog of patients who didn’t have access to surgery in the past.  In the first couple of missions that meant there were lots of older kids and adults in addition to infants, and now it means that the missions are still larger than usual as they continue to try to meet the country’s needs.  The team shirt is even different from the others I’ve received. They usually say something like, “Operation Smile Managua October 2012,” but this one says, “4th Maratón de Sonrisas.” (marathon of smiles.)

Despite all the hype, we had a pretty calm screening day.  We only saw 86 kids, so unless tomorrow is huge, this will likely be a more normal mission.  The surgery will be done at the children’s hospital, a change from previous years when they used the military hospital.  The hospital administrators and nurses seem very excited about hosting the team and it’s a great facility.  Its name is Hospitál Infantíl Juan Pablo II after Pope John Paul II.  Tomorrow morning at 7:00, the hospital is conducting a Mass for us before screening.  It’s a great honor so we’re all going and we Catholics will take it as a cultural experience.

There are several student volunteers from the Guatemala Montessori School, an English immersion school that goes from preschool through 12th grade.  They sound like native English speakers and of course also are native Spanish speakers.  Our VIP’s this time are Johnson and Johnson employees from Canada who won a company wide contest for raising the most money for Operation Smile over a three-month period.  There are three of them here and the “top” one explained to me that she raised enough for 24 smiles (at $240 per smile,) and the other two for 20 smiles each.

There were a few interesting patients today.  There was a six day old baby with a small unilateral cleft lip and normal palate.  His Dad brought him in on the off chance that we could fix it, even though he’d already seen two other surgeons who told him the baby needed to be about 10 pounds and 4-6 months old.  He was very sweet and a bit chagrined about the whole thing, and I think after seeing some of the babies with severe clefts, he calmed down and realized that it was OK to wait.  Nevertheless, seeing a parent in that situation really brings me back to the fact that this deformity is a huge shock for most parents and having to wait even one day to have it repaired is excruciating.  I also saw two 3 month olds who will have to wait a couple of months – again a big disappointment.

There was a very blue 8 pound 11 month old with a single chambered heart and cleft lip and palate that we also had to turn away.  He was so bright and alert and needs the surgery so that he doesn’t have to work so hard to eat.  However, it must be done somewhere with a pediatric ICU and pediatric cardiologists available and I don’t think, realistically, that it will happen.  What he really needs is a heart transplant.

Finally, we evaluated five kids today with complex syndromes that included clefts.  All were severely developmentally delayed and would have trouble tolerating surgery, so they won’t be on the schedule.  It’s always hard to be objective in deciding whether or not to operate on a severely delayed child.  If it will help with nutrition or breathing then it may be worth it, but particularly in the case of cleft palate, it’s not clear that the benefit is worth the risks of surgery or the painful recovery in a non-verbal child.

The internet at the hotel is currently down, but if it comes back up, I’ll post a few photos.  There are a couple pictures of a young man in a Dr. Seuss hat playing with a little girl and later holding a baby.  He’s one of the volunteer students from the Montessori school and plans to be a plastic surgeon so he can volunteer with Op Smile.

Arrival in Guatemala

Today I flew to Guatemala City via Atlanta, arriving at the Radisson Hotel at 1:50pm. I was a bit worried about getting delayed at customs or retrieving my luggage as I had assured the director of Heifer Project Guatemala that I could meet with him at 2:30.  All went smoothly, and Luis Fuentes, the director of the San Marcos clinic, who was also meeting with us, arrived at 2:00.  It was great to see him, and he showed me some recent photos of gardens in Tacaná.  To clarify, Tacaná is actually the name of the municipality of the high mountain region, and the village where I held a medical clinic in February lies within Tacaná and is called San Antonio.  Anyway, because of the lack of central village land, Luis has been building smaller home gardens on small plots between houses.  This has been very successful as the gardens are faster and easier to build and the families take great care of them.  They are already producing vegetables.

At 2:30, Gustavo Hernandez, the director of Heifer for Guatemala arrived.  We had a three way mostly Spanish - with a little English thrown in when I was stumped - conversation about Heifer's projects in Guatemala.  When I asked him why they had no projects in San Marcos, he said that they need to have someone in an area to collaborate with before they set up a project and when he took over in 2010, the previous director told him they didn’t have anyone in San Marcos.  Gustavo said that it is a priority for him to do some projects there, but they need to develop the infrastructure.
He then described a change in the philosophy of Heifer.  They’ve chosen 4 products, honey, cocoa, coffee and cardamon because these are big export crops of Guatemala.  Guatemala is the biggest producer of cardamon in the world and 350,000 poor rural farmers grow it in tiny plots and then it works it’s way up a pyramid to 8 exporters.  Heifer wants to change that so the growers gradually see the profits.  Coffee is grown on huge plantations where the poor do all the work. Same model, I think, for the poor to gradually become growers and processors???  They also have 4 program lines in a different wing, increasing women’s income, improvement of agricultural techniques and output, rabbit and chicken raising and something else.  Each project takes about a half million to run, a minimum of 1,000 people enrolled and runs for 3-5 years for data collection.  This is a big change from their previous model of giving animals to individual families.

We talked a lot about Tacaná and some of the other municipalities and their immediate needs, and I asked if they could do any animal  projects to provide protein for the people.  He said that he thought they could do what he called a “Pilot” program where they would figure out how many families were in need and how many say chickens and maybe rabbits could be bought. The money would also need to cover costs of assessing villages, finding families and training them in care of the animals and in the “passing on the gift” philosophy.  It’s not perfect, but he said even though their main thrust is on this new model, they still are about taking care of the poor and he can see that these communities need more immediate action.

I spent the rest of the afternoon unpacking and resting in my single room! Someone in the Radisson network is a big donor and provides the rooms free to the team.  It feels a bit decadent to be staying in such luxury, but having a single room is more logistical than luxurious.  I'm up earlier than most team members as I have to get to the hospital earlier to check the patients before surgery, and I'm the last one back to the hotel at night as I have to wait for the last patient to return from recovery.  When I have a roommate, I'm always having to tiptoe around in the dark so as not to wake her.

We had a team meeting/dinner and there are about 10 team members with whom I've been on prior missions.  It's very unusual to see so many, and makes for a nice reunion.  The project coordinator arranged for a marimba band to play during dinner. Seven men played on two big wooden instruments that resemble xylophones while another played a base and the last played drums.  It was very intricate and entertaining.  Tomorrow we tour the hospital and have the first of two screening days.

Returning with Operation Smile

   Next week I'll be returning to Guatemala City with Operation Smile.  As usual, this is a "last minute" trip I agreed to when the previous pediatrician had to drop out.  The mission coordinator wanted someone who could speak Spanish as most of the team members are either from Central or South America or have some degree of Spanish fluency.  Being able to communicate face to face makes a huge difference in team cohesion.  On a team where there are lots of people who need interpreters, breakfast in the hotel dining room takes me right back to high school - the football guys at one table, cheerleaders over there, eggheads (former term for geeks) at yet another, and finally, the daring "fast" kids, the envy of all of us, at a big table in the back.   As a former egghead, I am likely  over-analyzing and therefore overstating the resemblance to high school, but language segregation certainly prevents all the casual interchange that naturally brings people together.  It affects your ability to work together effectively and also has safety implications if urgent situations arise.

    Op Smile works really hard on safety in a variety of ways, and one is team cohesion.  There are always great interpreters where needed, but when they can put together a team like this one where most members can speak to each other directly, they prefer it.  The day before surgery begins, we always do the "name game," where we sit in a circle and each person has to go around and say all the names of the team members.  Having to memorize the names forces you to go up and introduce yourself in those first two days of screening and set up.  The only time I found it impossible was when I went to Namibia and a third of the team was from the Philippines; unspellable and unpronounceable names.

   There will be several returning team members from my previous trip to Guatemala and from missions in Nicaragua and Mexico.  It's unusual to see more than one or two familiar faces on a mission, so I'm looking forward to some reunions.  I likely will also see some children whom I saw for primary lip repair as infants who are now returning for palate surgery.  Finally, in relation to the Greenhouse Hunger Project that I'm working on with Luis Fuentes and Shuarhands in San Marcos, the director of Heifer Project, Guatemala has agreed to meet with Luis and me while I'm in Guatemala City about a possible collaboration.  I'm extremely excited about the possibility of bringing Heifer Project's  resources and animal projects to San Marcos.  It could mean more food, protein, and possible income opportunities for families... fantastic!