True to the plan to eradicate clefts, this is a gigantic mission. On most missions, there are two screening days with about 80-100 patients seen each day. The goal is to find about 100 patients who qualify for surgery over the four and a half surgical days. There are many reasons why a patient might not qualify for surgery. The two most common are age and weight. Op Smile follows fairly conservative guidelines, six months for lip repair and 12 months for palate repair. There is “wiggle room” in that a baby between three and six months who is very well nourished, has a good hemoglobin and a simple unilateral cleft lip might be approved for surgery, but only if all of the team leaders agree (surgery, anesthesia and pediatrics and the overall field leader.) Similarly, a well nourished baby with a good hemoglobin between nine and twelve months of age might have a palate repair if all agree. An “age deviation” form has to be filed with headquarters where it is reviewed by a committee set up for this purpose, and therefore the deviations are not agreed upon lightly. However, repairing cleft lips or palates can improve feeding and therefore nutrition, and certainly improve bonding and acceptance back into village life in the case of lip repair. This last reason can mean the difference between the father leaving the family in order to find work and being able to stay in his job in his home village. In extreme cases, the whole family may have been cast out of the village and repairing the lip will allow them to return home. Finally, a family may have travelled 10-12 hours by bus to come to the screening, and may not be able to afford to come again for another year or two. Delaying surgery this long can have major consequences for the baby.
The weight issue also has two sides. Skinny babies likely would gain better if they had their lips repaired. They do get an intensive trial of feeding therapy to increase their calories, but for many, they just can’t get enough suction until they’ve had the surgery. It comes down to weighing the risks of surgery and poor healing due to malnutrition against the known benefits of getting the lip closed.
Other kids don’t qualify due to current illnesses or newly discovered heart or kidney disease. I saw an eight month old in moderate congestive heart failure today. He hadn’t seen a doctor since his exam at birth and hadn’t been gaining well. Luckily there’s a good referral system here, and the local pediatrician was able to set up an appointment for him to see the cardiologist in the morning. There are also patients with problems that are too complex for this type of “in and out” mission. I saw two babies with holoprosencephally today, a major brain malformation that can include clefts. Both babies need major reconstructive surgery, probably in the US, and some surgeons on the team are talking about arranging it. Finally, some kids and adults come with non cleft related problems such as deafness, tongue tie, speech delay, scoliosis, in the hope that help will be available. Some can be referred to other specialists, but for others, help is not available here.
So, back to today. We saw 191 patients today for screening and will see at least another 100 tomorrow. Although there are six plastic surgeons plus three more who are training and six anesthesiologists with two who are training, there were just two pediatricians, me and Jen, the pediatrician who is on her first mission who is supposed to be "shadowing" me. Usually, the surgeons see all the patients first, then pediatrics and anesthesia team up as we are looking at generally the same things. However, this time, Jen and I were outnumbered, she had to dive in and head up one team while I did the other. This still left extra anesthesiologists who then started seeing patients on their own and bringing us the charts to sign. Neither of us were comfortable with this, but with 191 kids to see, it felt a bit churlish and uncomfortable to say we needed to see every patient. In the end, we compromised with anesthesia doing histories and Jen and I doing physicals. Luckily, no kid goes to the OR without a pre-op check by the pediatrician, so we'll have another chance to get our hands on them.
Besides the kids mentioned above, we saw at least a dozen other children with syndromes or previously diagnosed heart defects, deafness, dislocated hips and undescended testicles. I get the strangest looks when I'm checking pulses and genitals on these cleft missions, but often it's the only exam these kids will get, so I like to not miss anything. There will be six tables on this mission for four and a half days of surgery, and the hope is to operate on 150 patients. I haven't seen the ward yet, but a nurse who has been here before says it's one huge room with 40 beds. Perhaps I'll see it tomorrow and can get some photos. I did post just a few, but only one patient photo. There just wasn't time to get my camera out today.
Toward the end of the day they were short-handed in the lab where all the kids were having blood drawn. Everyone gets a complete blood count, clotting studies, and the kids having palate repair also get a blood type done. That means they all need blood drawn from a vein, and soon there was a huge line down the hall. A NICU nurse and I were called into the lab to help and as the pediatrician, I was, of course, expected to be GREAT at drawing blood. I actually used to be fantastic (brag, brag,) but it's been about six years, plus, for the first five kids, I was using a plastic (not even latex!) glove, cut in half, as a tourniquet. Luckily, it is a bit like riding a bike, and I had two of the Swedish nurses helping to hold, etc. Soon we had a rhythm and the Child Life person brought in her iPad to distract the kids. We cleared the place out in no time.
A final tid bit: On these missions, the pedi intensivist is also the designated Team Doctor. Any team member who gets sick reports to the PI who checks them and dispenses medication or treatment. Well...the PI doesn't arrive until the 21st so I am subbing for him. Today I saw a team member with a migraine, one with a badly bruised toe, (she dropped a big suitcase full of charts on her foot,) and one with vomiting and dehydration. Luckily no one showed up with chest pain or a hernia!
More tomorrow.
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