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!