Today we screened only 111 patients for a grand total of 313. After yesterday's 191 children, today felt almost leisurely. There were also two additional physicians helping with the screening today, a pediatrician from the hospital here who is trying to become Op Smile certified, and a Family Practitioner who is doing her pediatrics rotation. Their presence was a mixed bag and a bit dicey politically. Take the pediatrician. She is the only pediatrician in Honduras who is working with Operation Smile. She works in three hospital/clinics, the Social Security hospital which caters to "middle class" Hondurans who can pay for social security health coverage, the Children's Hospital, which is private but has good hearted specialists who will see children gratis for special, one time consultations, and the city hospital where we are which serves everyone whether they can pay or not. It's not really free as people are pushed hard to pay something, but prices are low and no one is turned away. She is the conduit through which I must go for any referrals I need.
As an example, I have seen three children so far with hearing loss due to severe dysfunction of their eustachian tubes - a common problem in children with cleft palate. They need to see and ear nose and throat doctor and an audiologist, and these are available to them at the children's hospital. However, there's a quota system, and the next appointments are in April. The kids' families have travelled many hours to get here and likely can't return for these appointments. The pediatrician will "do her best" to make it happen, but knowing what I do about what the families have endured to come here, I doubt it will happen.
She also has a very different approach to examining and treating children which is completely culturally based. There is nothing inherently wrong with her approach, but it can wreak havoc with screening for an Op Smile mission. The point of screening is to find kids who have a cleft lip or palate who can be treated on this mission. That means deciding if their age, current health, hemoglobin and general nutritional status are appropriate at this point in time. There is a set of questions to ask covering pertinent health history as it relates to the planned surgery, and this is followed by a focused exam. Estella, the pediatrician, delves into each child's past history whether or not it is relevant to the current surgery. Once a seizure at birth or murmur heard at the two month visit is uncovered, she can't let go of it. She writes on the chart in black marker, "needs echocardiogram prior to surgery," or "neurological evaluation" before surgery. It's nonsense, but with over 300 patients trying to fit into 150 spots on the schedule, these notations are the death knell. My job, as overseer of the pediatric team until the pediatric intensivist arrives on Sunday, is to make sure which of these exclusions are real and then try to get the bogus ones removed diplomatically.
It's also a strange position for me to be in because I am also mentoring Jen, the first time pediatrician from Seattle. She has had to jump in and be on one of the screening teams on her own, and has been fantastic, but has had some questions about how far to go with the examinations. As an example, she was seeing a boy who was here for a cleft palate repair and his mother had a concern about an undescended testicle. Jen's question wasn't whether to examine the boy and to ask how to refer him if need be, (he was fine,) but rather should she be examining all boys below a certain age to make sure the testes are descended, and all babies to rule out undetected hip problems. So, we had my "pediatricians as child advocates" talk and I gave her my take which is that this is likely the only pediatric exam the majority of these children will have and we should do the best "really fast exam under these circumstances" that we can. If we find something we should do our very best to get the child the referral he needs within the realities of where he lives, and then we should try to let it go.
As she goes on more missions, Jen will develop her own style and comfort level, and meanwhile, I continue to have to remind myself, we are not in the US and things are different elsewhere.
I want to get in some quick patient stories before we head off to the hospital for OR and ward set-up. I'm actually writing this very early Saturday morning. On the second screening day, I saw a 15 month old boy who was there for a palate repair. Dad came into my area in the middle of a heated argument with the anesthesiologist who was saying the baby needed an echocardiogram. The baby had been OK'd by the surgeon, anesthesia and pediatrics on the first screening day, but when he went to dental, the dentist found a badly abscessed tooth and cancelled surgery and gave Dad a bottle of antibiotic to take, telling him to return in three days for re-examniation and re-schedulling of the palate at next month's "in country" mission. Dad had completely forgotten about the whole dental thing, only remembering "come back for a recheck." When he returned on the second screening day, there was some sort of mix up, and the anesthesiologist who is not comfortable with pediatric murmurs and wants echo's on all of the babies with innocent murmurs, happened to be the one to screen him - thus the chaos. In mid argument, Dad suddenly remembered the antibiotic in his pocket, and sheepishly paused, hand in the air and confessed his story.
I also saw a seven year old boy who came from 8 hours away with his Dad. They just found out about this clinic on the radio. Dad had a cousin who died at birth who had a cleft lip and palate, so when his son was born with just a cleft lip, he assumed his son would die, kept him out of school and didn't expect much. Dad's a subsistence farmer and the boy is the 3rd of seven kids. As the boy grew older, he followed his Dad everywhere and now goes to the fields with him. They are extremely close and when his Dad found out his lip could be fixed, he made the journey here. However, when I saw him, he had a high fever and cough and turns out he has pneumonia. The anesthesiologist began telling the Dad that the boy could't have surgery but there would be other missions, and I could just see his face collapsing. I knew about the kids at home and figured he was thinking about how no one was providing for them while he was gone, how long this trip was, how unlikely they would be able to make another journey and how his son would likely never get his lip fixed. And then Estella swooped in, all smiles and began to talk, rapid-fire to the father. I had a hard time understanding it all, but there was a lot of, "no preocupe," (don't worry,) and "yo le cuidaré personalmente" (I'm going to take care of him personally, etc. The more she talked and fussed about the boy, the more the Dad brightened up. She told him she would take them down the hall over the the main hospital/clinic where the boy could stay over for a night or two to have treatment and Dad could stay with him. She would send them home with medicine and in one month, there was a local clinic with "the plastic surgeon who does the noses of the movie stars," and she would make all the arrangements for the boy to come back to have his lip fixed. So there you go.
My last patient story is of a 22 year old young man I saw who has never had his palate repaired and desperately wants it done. I don't know why it didn't happen when he was a year old or a toddler. After age 10 years, very good studies now show that closing the doesn't improve speech much at all, and surgeons don't like to repair palates in older teens and adults because complication rates are higher. This young man had a very good lip repair and is bright, well educated and has a good job. He wears an appliance in his mouth to close the gap, but still has liquid and food coming up through his nose when he eats, and therefore really wants his palate closed. Last November he came from 18 hours away by bus and was accepted for surgery here. However, something happened at the hospital half way through the mission, and they had to complete the surgeries at the Children's Hospital. He had just turned 21, and therefore was outside the age cutoff for that hospital and was bumped off the schedule. He was devastated.
This year, the director of Op Smile Honduras promised him (always dangerous,) that if he came back, she would fight for him to be included on the schedule. He came, but the problem this time is that there are over 300 patients for 150 slots. Operation Smile has a priority system they follow in deciding who gets surgery on each mission. To simplify, Priority One is patients with cleft lips who have never been treated. Priority Two is patients under age 10 with cleft palates, never treated, Priority 3, where this young man fits in, includes untreated clefts in older patients, among other things, and then there are Priorities 4 and 5 that I won't get into now. Many of the patients we have seen in screening are babies and children and some adults with lips that have never been closed. There are also many many patients under age 10 with primary palate closures. There is also a limit on the number of palate surgeries that can be done on each table each day as each takes about two hours. All of these factors made it very unlikely he would make the cut. It was heartbreaking to talk with him. He understood all of this and yet was still so hopeful and asking us to pray for him. I'll talk more about how it happened later, but several people were pulling for him and he is on the schedule for Tuesday!!
It's time for a little levity. As in many hotels, you get a key card rather than an actual key to get into your room. You also have to stick it in a slot in the elevator and push your floor's button to get the elevator to go there. The problem is that using the keys in the elevators is not at all intuitive. There's an arrow on one side and a magnetic strip on the other and the way you put it in is very confusing. When a crowd gets on the elevator, there's a mad rush to get the cards into the slot for your floor. The slot is very conveniently placed about 12 inches up from the floor of the elevator, so everyone is crouching down and trying to keep their faces away from the, hmm, backsides of the other passengers. Cards are dropped and stepped on, floors passed by without the door opening, curses whispered. The final insult is that there are two elevators, and the two slots accept their cards differently. One likes them strip up and the other strip down. There's probably a security video of this process gone viral somewhere. Yesterday when the team returned from the first screening day, hot, tired and some cranky, all the room keys had lost their codes or whatever they have to have to open your door. They all had to be re-magnetized at the front desk. It was not a happy scene.
OK, I have 10 minutes to describe patient selection and then I'm off to the hospital. Usually the team leaders of which I am not one, go through every chart, starting with P1 and ending with P5 to decide who will have surgery and who will not. I'm included in the process this year because the intensivist who would usually do this, doesn't arrive till Sunday. Some kids get bumped because their hemoglobin is too low (anemia) or some other health problem comes to light. Some get bumped due to age - the surgeon says OK to a 4 month old for a lip but the pediatrician or anesthesiologist says no, the baby is too young, etc. The limiting factor on this mission turned out to be the plethora (great word,) of palates. Honduras is trying to eradicate clefts, and there are many people coming out of the woodwork who didn't know they could get their palate fixed. There was a lot of discussion of how to decide which ones could and couldn't be done, which would have to wait until the next mission. In the end, they decided to do palates on four days instead of three. This means all the palates can be done but puts a big burden on the post op nurses on that last day. Palate patients only stay overnight, but they often don't go home until the afternoon of the next day. Friday is a half day, just light cases, but now there will be a ward full of recovering palate cases as well. It's clearly the right thing to do but will mean a very heavy mission overall.
It was fascinating for me to sit in on this as the personalities of the people involved come out full force. The surgeon, Michael, who is from Ireland and is around my age, thinks like I do - we're here for 10 days so lets work as hard as we need to to get as many patients treated as we can, even if that means working late. Mercedes, the anesthesiolgist from Honduras is always trying to cut patients and limit the number of patients - "too long surgery, too difficult intubation, too hard on anesthesiologist." The clinical coordinator is trying to maximize the number of cases, keep above the emotions of the group and make the mission go smoothly, but he also is trying to keep the nurses from being overwhelmed. I kept my mouth shut, challenged no one until the 22 year old young man came up and then respectfully told his story as best I could and asked everyone to please consider his case and do his surgery. After a round of "no's" we had a discussion, and in the end, everyone but the anesthesiologist agreed and he will be done!!
OK, off to breakfast.
As an example, I have seen three children so far with hearing loss due to severe dysfunction of their eustachian tubes - a common problem in children with cleft palate. They need to see and ear nose and throat doctor and an audiologist, and these are available to them at the children's hospital. However, there's a quota system, and the next appointments are in April. The kids' families have travelled many hours to get here and likely can't return for these appointments. The pediatrician will "do her best" to make it happen, but knowing what I do about what the families have endured to come here, I doubt it will happen.
She also has a very different approach to examining and treating children which is completely culturally based. There is nothing inherently wrong with her approach, but it can wreak havoc with screening for an Op Smile mission. The point of screening is to find kids who have a cleft lip or palate who can be treated on this mission. That means deciding if their age, current health, hemoglobin and general nutritional status are appropriate at this point in time. There is a set of questions to ask covering pertinent health history as it relates to the planned surgery, and this is followed by a focused exam. Estella, the pediatrician, delves into each child's past history whether or not it is relevant to the current surgery. Once a seizure at birth or murmur heard at the two month visit is uncovered, she can't let go of it. She writes on the chart in black marker, "needs echocardiogram prior to surgery," or "neurological evaluation" before surgery. It's nonsense, but with over 300 patients trying to fit into 150 spots on the schedule, these notations are the death knell. My job, as overseer of the pediatric team until the pediatric intensivist arrives on Sunday, is to make sure which of these exclusions are real and then try to get the bogus ones removed diplomatically.
It's also a strange position for me to be in because I am also mentoring Jen, the first time pediatrician from Seattle. She has had to jump in and be on one of the screening teams on her own, and has been fantastic, but has had some questions about how far to go with the examinations. As an example, she was seeing a boy who was here for a cleft palate repair and his mother had a concern about an undescended testicle. Jen's question wasn't whether to examine the boy and to ask how to refer him if need be, (he was fine,) but rather should she be examining all boys below a certain age to make sure the testes are descended, and all babies to rule out undetected hip problems. So, we had my "pediatricians as child advocates" talk and I gave her my take which is that this is likely the only pediatric exam the majority of these children will have and we should do the best "really fast exam under these circumstances" that we can. If we find something we should do our very best to get the child the referral he needs within the realities of where he lives, and then we should try to let it go.
As she goes on more missions, Jen will develop her own style and comfort level, and meanwhile, I continue to have to remind myself, we are not in the US and things are different elsewhere.
I want to get in some quick patient stories before we head off to the hospital for OR and ward set-up. I'm actually writing this very early Saturday morning. On the second screening day, I saw a 15 month old boy who was there for a palate repair. Dad came into my area in the middle of a heated argument with the anesthesiologist who was saying the baby needed an echocardiogram. The baby had been OK'd by the surgeon, anesthesia and pediatrics on the first screening day, but when he went to dental, the dentist found a badly abscessed tooth and cancelled surgery and gave Dad a bottle of antibiotic to take, telling him to return in three days for re-examniation and re-schedulling of the palate at next month's "in country" mission. Dad had completely forgotten about the whole dental thing, only remembering "come back for a recheck." When he returned on the second screening day, there was some sort of mix up, and the anesthesiologist who is not comfortable with pediatric murmurs and wants echo's on all of the babies with innocent murmurs, happened to be the one to screen him - thus the chaos. In mid argument, Dad suddenly remembered the antibiotic in his pocket, and sheepishly paused, hand in the air and confessed his story.
I also saw a seven year old boy who came from 8 hours away with his Dad. They just found out about this clinic on the radio. Dad had a cousin who died at birth who had a cleft lip and palate, so when his son was born with just a cleft lip, he assumed his son would die, kept him out of school and didn't expect much. Dad's a subsistence farmer and the boy is the 3rd of seven kids. As the boy grew older, he followed his Dad everywhere and now goes to the fields with him. They are extremely close and when his Dad found out his lip could be fixed, he made the journey here. However, when I saw him, he had a high fever and cough and turns out he has pneumonia. The anesthesiologist began telling the Dad that the boy could't have surgery but there would be other missions, and I could just see his face collapsing. I knew about the kids at home and figured he was thinking about how no one was providing for them while he was gone, how long this trip was, how unlikely they would be able to make another journey and how his son would likely never get his lip fixed. And then Estella swooped in, all smiles and began to talk, rapid-fire to the father. I had a hard time understanding it all, but there was a lot of, "no preocupe," (don't worry,) and "yo le cuidaré personalmente" (I'm going to take care of him personally, etc. The more she talked and fussed about the boy, the more the Dad brightened up. She told him she would take them down the hall over the the main hospital/clinic where the boy could stay over for a night or two to have treatment and Dad could stay with him. She would send them home with medicine and in one month, there was a local clinic with "the plastic surgeon who does the noses of the movie stars," and she would make all the arrangements for the boy to come back to have his lip fixed. So there you go.
My last patient story is of a 22 year old young man I saw who has never had his palate repaired and desperately wants it done. I don't know why it didn't happen when he was a year old or a toddler. After age 10 years, very good studies now show that closing the doesn't improve speech much at all, and surgeons don't like to repair palates in older teens and adults because complication rates are higher. This young man had a very good lip repair and is bright, well educated and has a good job. He wears an appliance in his mouth to close the gap, but still has liquid and food coming up through his nose when he eats, and therefore really wants his palate closed. Last November he came from 18 hours away by bus and was accepted for surgery here. However, something happened at the hospital half way through the mission, and they had to complete the surgeries at the Children's Hospital. He had just turned 21, and therefore was outside the age cutoff for that hospital and was bumped off the schedule. He was devastated.
This year, the director of Op Smile Honduras promised him (always dangerous,) that if he came back, she would fight for him to be included on the schedule. He came, but the problem this time is that there are over 300 patients for 150 slots. Operation Smile has a priority system they follow in deciding who gets surgery on each mission. To simplify, Priority One is patients with cleft lips who have never been treated. Priority Two is patients under age 10 with cleft palates, never treated, Priority 3, where this young man fits in, includes untreated clefts in older patients, among other things, and then there are Priorities 4 and 5 that I won't get into now. Many of the patients we have seen in screening are babies and children and some adults with lips that have never been closed. There are also many many patients under age 10 with primary palate closures. There is also a limit on the number of palate surgeries that can be done on each table each day as each takes about two hours. All of these factors made it very unlikely he would make the cut. It was heartbreaking to talk with him. He understood all of this and yet was still so hopeful and asking us to pray for him. I'll talk more about how it happened later, but several people were pulling for him and he is on the schedule for Tuesday!!
It's time for a little levity. As in many hotels, you get a key card rather than an actual key to get into your room. You also have to stick it in a slot in the elevator and push your floor's button to get the elevator to go there. The problem is that using the keys in the elevators is not at all intuitive. There's an arrow on one side and a magnetic strip on the other and the way you put it in is very confusing. When a crowd gets on the elevator, there's a mad rush to get the cards into the slot for your floor. The slot is very conveniently placed about 12 inches up from the floor of the elevator, so everyone is crouching down and trying to keep their faces away from the, hmm, backsides of the other passengers. Cards are dropped and stepped on, floors passed by without the door opening, curses whispered. The final insult is that there are two elevators, and the two slots accept their cards differently. One likes them strip up and the other strip down. There's probably a security video of this process gone viral somewhere. Yesterday when the team returned from the first screening day, hot, tired and some cranky, all the room keys had lost their codes or whatever they have to have to open your door. They all had to be re-magnetized at the front desk. It was not a happy scene.
OK, I have 10 minutes to describe patient selection and then I'm off to the hospital. Usually the team leaders of which I am not one, go through every chart, starting with P1 and ending with P5 to decide who will have surgery and who will not. I'm included in the process this year because the intensivist who would usually do this, doesn't arrive till Sunday. Some kids get bumped because their hemoglobin is too low (anemia) or some other health problem comes to light. Some get bumped due to age - the surgeon says OK to a 4 month old for a lip but the pediatrician or anesthesiologist says no, the baby is too young, etc. The limiting factor on this mission turned out to be the plethora (great word,) of palates. Honduras is trying to eradicate clefts, and there are many people coming out of the woodwork who didn't know they could get their palate fixed. There was a lot of discussion of how to decide which ones could and couldn't be done, which would have to wait until the next mission. In the end, they decided to do palates on four days instead of three. This means all the palates can be done but puts a big burden on the post op nurses on that last day. Palate patients only stay overnight, but they often don't go home until the afternoon of the next day. Friday is a half day, just light cases, but now there will be a ward full of recovering palate cases as well. It's clearly the right thing to do but will mean a very heavy mission overall.
It was fascinating for me to sit in on this as the personalities of the people involved come out full force. The surgeon, Michael, who is from Ireland and is around my age, thinks like I do - we're here for 10 days so lets work as hard as we need to to get as many patients treated as we can, even if that means working late. Mercedes, the anesthesiolgist from Honduras is always trying to cut patients and limit the number of patients - "too long surgery, too difficult intubation, too hard on anesthesiologist." The clinical coordinator is trying to maximize the number of cases, keep above the emotions of the group and make the mission go smoothly, but he also is trying to keep the nurses from being overwhelmed. I kept my mouth shut, challenged no one until the 22 year old young man came up and then respectfully told his story as best I could and asked everyone to please consider his case and do his surgery. After a round of "no's" we had a discussion, and in the end, everyone but the anesthesiologist agreed and he will be done!!
OK, off to breakfast.
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