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.