Final Wrap-up

Well, it's March 6th and a very late final wrap-up, but after only two days at home, I flew to Seattle where I am spending 10 days with my daughter and two grandchildren while my son-in-law is in Peru on a work related project.  It's 5:00 am and for the moment, I'm the only one awake. We'll see if I can get this written.

The Honduras mission accomplished 134 surgeries, a few short of the goal of 150, but due to the high number of patients at screening who needed palate surgery, 150 turned out to be unrealistic.  Palates take a minimum of two hours, and often three to repair whereas most lip repairs are one to one and a half.  At followup a week later, 120 patients were seen and there were no complications.  The local Honduran Operation Smile group is amazing.  They have so much less money than some of the other local organizations such as the ones in Nicaragua and Mexico.  Those have the support of big corporate sponsors upon which to build their fundraising.  In Honduras, they are mainly funded by many small local donors, except for their beautiful clinic which a Japanese company funded in 2006. Despite their "bare bones" operation, they have decided on this lofty goal of eradicating clefts, and are putting the word out all over Honduras that free surgery is available.  Many of the older children and adults seen on this mission were from tiny remote villages where they had been hidden away for years, unaware that there was help available.  One dream of Op Smile Honduras is that no-one with a cleft will be hiding; they all will come out and be treated.  The other dream goes with the first.  People will know about Op Smile and babies born with clefts will all will be treated in infancy so there will be no need to hide.
That's all. I'm going to Ethiopia in June and will send out a link.

Fourth day of Surgery and my final day 2/25/16

I just re-read and edited yesterday's post.  I wrote it after about four hour's sleep and it needed a bit of cleaning up.  Today was my last day as I am leaving tomorrow so that I can be home in time to Chair the board meeting for Clarke. (www.clarkeschools.org for those who'd like a look.) The airport was closed yesterday due to winds, so I hope it's open tomorrow.
Today was a slower day for the ward because the surgeons had scheduled fewer but more complex and therefore longer cases.  We only had 22 as opposed to 33 patients today, and it was nice to have a slower pace.  Jen went to the ward to check on the boy who was cancelled because of his respiratory infection and wheezing yesterday and brought back a photo of his chest X-ray on her cell phone.  It turns out he has a big pneumonia so she felt vindicated.  Perhaps she'll email it anonymously to the PI.  There was an 18 month old with a history of asthma and developmental delay who had his palate repaired today.  After surgery, he had a very hard time recovering.  He spent most of the day in the PACU on oxygen, getting various drugs IV and by nebulizer. He finally stabilized enough to come to the ward and looked well on room air by the time we left tonight.  It brought up a big discussion of the screening process, how cases are chosen, which kids should be excluded, etc.  Here's my opinion: One should try to do the lip repair on almost every child.  I say this because even if the child has very little function, making their appearance more "normal" helps their parents and other family members bond with them and in certain countries and villages helps the family be able to be included in the village again.  With palate repair I find it more difficult.  The recovery from palate surgery is difficult and painful.  The main benefits are better speech quality and less regurgitation of food through the nose, and perhaps less choking while eating.  If a child has profound cognitive deficit and no language, I would find it hard to recommend putting the child through palate repair unless their were major feeding issues that the speech/feeding therapists felt would be helped by the surgery.
OK, now to stories and brief thoughts before it gets too late.
On the light side:

There are generally no paper towels or electric blow dryers in the bathrooms in the hospital.  The action is, wash hands, shake off the water, wipe on pants.  Everyone has the remnants of water handprints on their pants.

There is never any toilet paper in the bathrooms.  Everyone tries to remember to bring some from their hotel room, but paper napkins from breakfast, paper towels, any little bit of relatively soft paper is gold.  People are on the lookout and pick it up and stuff it in their pockets as they go by.

Most babies with cleft lips go right to the bottle here. I only saw three breast feeding babies and they are allowed to go right to the breast after lip surgery.  Bottles are not allowed for six weeks.  As you might imagine, the nursing babies are in heaven on the ward and the rest are very jealous. 

If a parent takes off work for their child to have surgery or a child misses school to come to the hospital for the sibling's surgery, they have to have a letter from the treating doctor,(or colleague,) to get back into work or school.  I can't write the letters as I'm not licensed in Honduras.  Parents line up outside the OR for hours,waiting for a surgeon to come out to sign the form letters.  They have to be signed on the day of discharge and then date stamped at the main office of the hospital.  They can't be pre-signed.

I can't remember if I mentioned that the women who mop the corridors have to wash out their mops by hand in outside stone basins (photos on Picasa.) Perhaps the sheets are also washed by hand in another part of the hospital??

There is lots of construction going on at the hospital with open pits of gravel, rebar sticking out of the ground, big and small holes everywhere.  I find I have my eyes on the ground at all times.

When we had to transfer a child from the post-op ward to the inpatient ward, we discovered that the child's hospital chart (as opposed to our Op Smile chart,) had been left in the pre-op ward when the child went to surgery.  All the kids have the two charts as they are considered in patients of the hospital while they are on our "service."  I went to get the chart, but they wouldn't give it to me.  We had to take the child back to pre-op, and the pre-op nurse could then release the child AND the chart to the nurse from the inpatient ward.  SHEESH.

One of the team nurses who comes from Bolivia arrived at the mission feeling a little bit feverish. She got joint pains and fatigue and it turns out she has Dengue fever.  Now one of the Swedes also feels bad and had her blood drawn today.  I haven't seen any mosquitoes and no bites.  I think they don't like the taste of me.

I'll finish today with the story related by LiDeny, the Honduran pediatrician who has been working with us this week.  She is trying to finish her credentialing as an Op Smile pediatrician, and the last step is to work on an international team and be evaluated (by me.)  Anyway, she works three different jobs adding up to 60-80 hours per week, and her husband who is an OB Gyn does the same.  They have two children, a 19 year old son and a 15 year old daughter.  LiDeny explained that just as the poor of Honduras save every penny to make sure their kids can rise out of poverty through education, the more well-to-do like she and her husband work and save to send their kids to school outside of Honduras.  They do it, she says for two reasons. The first is safety.  She said that a well off boy, in particular is a target for kidnappers who think they can get a big ransom.  If they don't get enough money, they kill the boy as an example for other parents.  Her son had two friends who were killed by kidnappers. He is now in university in Plattsburgh, NY where he is studying economics and business. He is fluent in English, French, Mandarin and Italian from his private grade and high schools and has a $3500 a year scholarship.  She and her husband have to pay $10,000 twice a year which they consider a great deal for this public education in the US.  He earns pocket money tutoring other students and maintains a 4.0 grade average.  If he keeps his 4.0, he gets monetary bonuses each semester of Amazon or store gift cards that help with expenses.  If it drops below 4.0, he doesn't get the bonuses. Her daughter has been going to a French immerse school at the French Embassy since age three and is fluent in French, English and is working on Mandarin and Italian.  They love the US because they feel the US people value educated people who know languages and will provide good jobs for her children when they are done with school.  Meanwhile, they will be safe from kidnappers.
That's all for now.  I'll do some wrapping up in a day or two

Second and Third Days of Surgery and Various Observations 2/24

I'll try to do some catching up on this posting.  It's 10:30 pm on Wednesday. We got back to the hotel at around 10 tonight; each night we've left the hospital about an hour earlier than the previous night.  Last night I was too exhausted to do more than check a few emails, but I've been keeping some notes, so I'll try to re-create some of my adventures. After the first day's fiasco with so many crying and agitated kids, I had a conversation with the intensivist and the anesthesia team leader and the Swedish anesthesiologist. Now that it's Thursday morning and I'm reviewing my posts, I realize that  you need some background before I go on.  I'm used to working closely with the pediatric intensivist (PI) on these missions. He or she is usually just that, but the role can also be filled by a pediatric anesthesiologist, and in those cases, the dynamic is a little different than it is between two pediatricians.

The PI on this team is an anesthesiologist, and though he came with a reputation for being great to work with, my interactions have not been as collegial as on previous missions.  Some of it is not his fault, but rather is due to the strict rules maintained by this hospital on who may or may not enter the PACU.  I'm used to being able to go into the PACU to discuss cases or to talk about a child still recovering there, to get a better sense of the PI's thoughts on what we may be needing to do once the child comes to the ward.  Here, no one who is not on the PACU team may enter, so I only speak to the PI if I stand outside the door to the PACU and he comes out.  So, on Monday, many of the kids returned to the ward very agitated, crying and thrashing around for up to 45 minutes.  We had a hard time with pain control, and as you might imagine, the parents were very unhappy.

The Swedish team and the nurse from Finland had both brought big supplies of clonidine to use during induction of anesthesia as it is used extensively in Sweden and some other European countries and makes for much less pain and agitation post-op.  Long lasting local blocks are also used and also Nubain, another sedating pain killing drug.  Various combinations can be used before the child comes to the ward so that the child arrives relatively comfortable and we can maintain that comfort with just acetaminophen  and ibuprofen.  On Monday, the cause of the ward full of very uncomfortable kids was a decree by the PI, banning the use of clonidine.  He felt that it would make the kids too sleepy to be sent to the ward, and the PACU would back up with sleeping kids.  Clonidine is sedating, but it doesn't depress the respiratory drive and the kids are easily wakened to drink fluids, etc.  There wasn't much Nubain in the cargo, so without clonidine, blocks were the only option and they wore off quickly.  The PI was giving small does of propofol, a general anesthetic in the PACU, and by the time the kids reached the ward, the propofol was wearing off leaving a thrashing child who was in pain.  There's been a fair amount written about "emergence syndrome" where kids come out of anesthesia very agitated before they are fully awake.  Some people don't think it's, real, but after seeing so many kids go through a similar reaction on these missions, I'm a believer.

So, back to my conversation with the PI and anesthesiologists.  The PI's first response was to imply that we, the pediatric team, just wanted a sedated, quiet ward so we wouldn't have to work so hard.  The "nice" Dr. Bartlett disappeared for a moment or two and disabused him of that impression, letting him know that his remarks felt a "bit condescending." He backed off a bit and we had an actual conversation.  Anesthesia joined in,  clonidine came back into the mix, and Tuesday was a much better day in terms of comfortable kids.  However, we had several kids arrive at pre-op with fevers and colds resulting in reschedulings or cancellations. Jen, the other pediatrician who is on her first mission and thinking with her "doctor who practices real medicine in the US," brain felt very strongly that one of these kids, a two year old with a bad cold, retractions, borderline oxygenation and wheezing should not have surgery this week.  The PI thought we should treat his wheezing aggressively and reschedule him for later in the day.    The  PI's argument was that there is a narrow window for closing the palate and getting good speech.  If the palate is closed before age three or so, and the child gets good speech therapy, his speech can be close to normal.  The older a child gets before the palate is closed, the less likely he is to have a normal quality to his with a repaired palate.  After age 12years or so, there is unlikely to be any benefit to speech.  This child lives far away and is likely to have the usual 8-10 viral infections a year and so may never be "well" when a mission comes around.  The PI felt that with his expertise in the PACU and the expertise of the two pediatric anesthesiologists on the team, any difficulties the child might have could be managed.

I could actually see both sides of the hypothetical argument, though I came down on the side of not having this particular child go to surgery this week; he was just too sick.  Luckily, the anesthesia team leader decided the issue. She said no for a different reason.  She said that if the surgery was done when the child was coughing so hard, he was likely to disrupt the repair and end up having to have it redone.  Anyway, the end result was that the child was admitted to the hospital's pediatric ward for treatment, and Op Smile will try to reschedule him for June.

Aside from the respiratory illnesses, the other interesting story was that the 22 year old young man with the cleft palate had his surgery done. He was supposed to have had it done in November but was cancelled when the mission was moved to the children's hospital and he was too old for the hospital's "mission guidelines."  He almost didn't have it this time because there were too many younger patients, but a few of us fought for him and he finally had it done.  He was so happy! He had brought a small mirror and he kept sticking it in his mouth and checking out his new palate.  There was one little glitch when he asked to get up and walk to the bathroom.  A nurse wanted to go with him, but since there are no male nurses he refused.  Once in the bathroom, he fainted, falling halfway into the toilet.  He wasn't injured and recovered fairly quickly, but it added to the day's excitement.  The surgeons finally gave up yesterday evening around 10:30pm and bumped the remaining four patients  to Wednesday.

Wednesday was bleeding day.  Four patients with palate surgery had bleeding and had to go back to the operating room.  Before they went back, we tried all sorts of maneuvers that you learn if you've been an Op Smile volunteer for awhile.  You rinse out clots, apply pressure, have the patient gently swish ice water, apply more pressure, watch, wait... Eventually, you call the surgeon to come look and he or she goes through the same maneuvers again and then takes the child to the OR to fix the bleeder.  It's exhausting for the child and parents, and ties up at least one doctor and nurse for each bleed on a very busy ward.  Having four patients go through it today made for chaos.

Two patients tried to swallow their tongue stitches today.  The stitch is put through the tongue and then brought out and taped onto the cheek.  The next day the surgeon clips it and removes it.  The purpose of the stitch is to have something to grab onto to pull the tongue forward if the child is bleeding heavily or the tongue is swollen and blocking the airway.  Until today I'd never seen the stitch used, and one of the nurses and I composed a letter to Op Smile last year proposing a five year retrospective study to see how often they were actually needed and whether Op Smile should reconsider using them.  Today, four patients, two with bleeding and two with very swollen tongues, post-op, needed the stitches to pull their tongues forward.  The two swollen tongues were due to prolonged surgeries with the tongue being held in the "Dingman"(an apparatus that holds the mouth wide open for palate surgery and presses down on the tongue.) for a long time. So much for our study.

So, back to the suture swallowers.  The kids hate the stitches and are drooling as it hurts to swallow after palate surgery, so the cheek, where the stitch is taped, is wet.  If the tape comes off, the child can snake their tongue out and pull the stitch into the mouth.  They can't really swallow it as it's sewn through the tongue, but they can try.  The first was a four year old boy, and his was so far down his throat that I could only see a tiny bit of it.  I managed to grab the tip with a surgical snap, but he was biting so hard on the snap, and trying to bite me that I was afraid he'd break a tooth or bite off my finger. I ended up cutting and removing the stitch. The other was a 14 month old girl, and her stitch was easy to grab and pull back out of her mouth.  Getting it taped again was another story as I could not keep her cheek dry.  I finally got the tape on after three failed attempts, but it may not hold till morning.

I posted some photos of the corridors and grounds of the hospitals. The corridors are all exterior and tiled, and there's a legion of women whose job it is to mop them continuously.  The tiles are always damp and a little muddy and very slippery. There are a couple of photos of a woman washing out her mops outside in stone scrub basins; hard physical labor with what I expect is very low pay.  I also posted a couple of photos of our "cafeteria."   In real life, I think,  it's a small storeroom re-purposed for the mission.  Local volunteers come in and lay out food they've cooked at home. Lunch yesterday was a rice dish with shrimp but the day before was a typical Honduran chicken barbecue.  I usually eat some tortillas and beans on the run and fruit in my room. Breakfast at the hotel is great so I load up there.

The hotel is patrolled by young soldiers in camouflage with big guns. They march around in lockstep, in formations of six or eight soldiers, guns held upright in front of them, looking very serious.  I've tried a few times to say good morning, but neither eye contact nor conversation with civilians are on the agenda.  At least I know I am SAFE!!!

I have a few more things to write about, but it's time to head to the hospital.  I leave for home tomorrow as I have the Clarke meetings Saturday.  I should have more time to write later today.

First Day of Surgery - 2/22/16

I'm writing this at 4:15 on Tuesday morning after about four hours of very fitful sleep.  I finally gave up and decided I might as well do something productive like describe my day instead of trying to rest up for day two.  Much of the day yesterday I had visions of a riptide.  Wikipedia, that unimpeachable source of information defines a riptide as "a tide that opposes another or other tides, causing a violent disturbance in the sea."  The two opposing tides were the strong desire to get as close as possible to the Honduran Eradication Campaign's 150 patients treated goal versus the reality of the first surgical day being slow. The first case of the day always starts at least an hour late because there are inevitable last minute glitches.  An oxygen fitting needs to be changed, the right sutures can't be found, decisions about which surgeon works with which anesthesiologist need to be juggled.  And then each operation takes longer on the first day, or at least the first morning.  It's only natural that the surgeons and their teams need to get used to operating together.  Everyone knows all of this, but instead of scheduling fewer patients on the first day, the schedule always seems to be packed just as full of patients as all the other days.  There is always a spirit of  "we can do it-ism" when we really can't.  On top of it, four more patients showed up yesterday, having heard about the mission and wanting to be seen.  Two were six month old infants who needed lip surgery and are "Priority 1" meaning they can bump Priority 2 or 3 off the schedule.  The other two were older and though they were not as urgent, they were also added to the schedule.  In fact, three of the four were added on to yesterday, even though we were already two hours behind when they came.

OK, enough venting except to say that in the end, the surgeons were still in the OR at 10 pm and the last patient reached the ward at 11:30.  I was in bed by 12:15 but so wired that sleep was marginal.  Right now I'm still full of nervous energy that I hope will last until the end day two, rather than disappearing in the middle.  The other inevitable outcome of  this riptide was that two patients  who had waited all day ended up having their surgery cancelled and rescheduled for this morning.  One was a three year old boy who was scheduled for a palate repair at 4:00.  He had his last solid food at 7:00 pm on Sunday and we gave him apple juice every two hours on Monday to keep him hydrated.  Each time he finished his four ounces, he would give an exaggerated lip smack and fling the cup across the room.  He would then dash to retrieve it, and for the next hour or so, he would entertain himself, using the cup as his soccer ball, hat, baseball, (using the long box that had housed the stack of cups as his bat,) or hiding a small car I had given him inside it.  Eventually he would lose interest and abandon the cup, only to start again after the next round of juice.  Around nine in the evening he got cranky and by ten he was out of patience.  When the coordinator cancelled his surgery, his parents were very gracious, but those of us who had been watching him all day almost cried. The family lives in town so they slept at home.  We'll see how he is when he arrives back on the ward this morning.

My day started with breakfast at 5:45, getting on the van at 6:00 with Jen, the first time pediatrician from Seattle, and three of the pre/post (ward) nurses.  We paused to greet the hospital nurses with chocolates that Kara, our coordinator had managed to find for me on Sunday and spent about five minutes thanking them for hosting us and asking them to please keep an eye on us the first day to let us know if we were doing anything that should be done differently.  We all made a point of stopping by their station periodically in the morning to chat for a minute or two or ask their advice, and when Kara bought us a basket of big fried buns filled with shredded pork, (mid morning snack provided by a Honduran volunteer,) we took it right over to their station to see if they would like to share.  The buns disappeared, sealing our friendship with the ward nurses and solving our dilemma of not hurting the feelings of the volunteer by sending back a basket of uneaten pork buns.

The pediatric team goes to the hospital half an hour early to get the first two patients for each of the six tables ready for the OR so that surgery can start promptly at 7:00. That should happen the rest of the week.  Once the first two rows are ready, we can get the rest set at a more leisurely pace.  Getting them ready involves checking vital signs, exam and making sure labs, consents, and all the other pre-op details are set.  In this particular hospital, the OR is not close to the wards, and the pre-op and post-op wards are not close to each other.  We started out trying to communicate with cell phones, but reception was poor in the OR. We changed to walkie talkies, but static made those unworkable.  What ended up happening was that Yazan, our clinical coordinator who calls to pre-op and asks for patients to be sent to the OR, would call me on the walkie talkie and say, "send patients number garble garble garble to the OR now."  I would then trek down to the OR where he would tell me who to send and then I would go back to pre-op and tell the nurse who would round them up and take them down.  We tried several times to get a system going using the hoard of teenage volunteers as runners, but they were a bit too much in the party mode to be relied upon. Later I learned that most are children of staff physicians and "volunteer" to get together with their friends rather than to work.  I'm not sure what we'll do today.
I'm going to post a few photos - I didn't have a chance to take many. One is of me in a funny hat. There's a tradition of Op Smile is to have a king and queen for the day, the first day chosen by the project coordinator for service of some type. The subsequent kings and queens are chosen by whoever got the first hats.  I was chosen because I stepped in for the Intensivist who came late.  That's it for now.

Team Day and a conversation with the ex-President of Honduras 2/21/16

Today was Team Day, an Operation Smile tradition.  The day before surgery is always spent doing some relaxing activity where team members can take the time to get to know each other better and take a deep breath before the whirlwind of the surgery week begins.  We drove to Valle de Angeles, a small town about 45 minutes from Tegucigalpa that is primarily a tourist destination.  It has narrow dirt or cobblestone streets lined with small shops selling a variety of local crafts.  The quality of the items varies widely, but most are authentic and made by the seller.  Some things, like the tightly woven pine needle baskets, come from other regions of the country, so they are sent by the artisans to one of the three larger "galleries" here or to cousins or other family members who live in the town.  Most of the sellers give Operation Smile team members an extra discount, likely because a team comes at least three times a year with lots of business.

After a couple of hours in town, we went to the home of the former president of Honduras, Ricardo Maduro.  He's a big supporter of Operation Smile and lives in a beautiful old home on a few acres of land at the edge of town.  We had pupusas: flour tortillas with cheese or beans layered between them and topped with chilis, tomatoes and shredded cabbage.  Two women made them while we watched and a couple of guys from the team tried their hand.  There were also chorizos and a fudge-like cookie and, of course beer.  There were mango trees on the property and I was hoping we would have fresh mangos for dessert.  Indeed, after the pupusas were gone, a woman came around with a plate offering mangos.  However, they had been sliced, heavily salted and peppered and mixed with chilis.  I didn't cry, but it was a close thing.

Near the end of our visit, a rather small, slender man and his wife came up to me on the patio and introduced themselves.  At first, I didn't know who it was as I hadn't gotten the word that we were at the ex-president's house and therefore wasn't expecting to run into him.  In the course of the conversation I learned that he was Ricardo Maduro who had been the president of Honduras from 2002-2006.  However, that fact didn't come up until we'd been talking for at least 15 minutes.  He spoke to me in perfect English, and it soon came out that he had gone to prep school in New Jersey at the Lawrenceville School and then to Stanford.  He graduated two years ahead of me so we were there at the same time.

 On returning to Honduras, he worked for Xerox and then was tapped by the President of Honduras to head the finance department of the government.  Later he was the President of the Bank of Honduras, but in 1997, his 25 year old son was kidnapped and despite him paying the requested ransom, his son was killed. He told me that this event and his subsequent depression and recovery changed his approach to life.  Where before he had been a fairly hard-nosed  businessman, he now just wanted to work on getting rid of crime, getting the poor a fair deal and getting education to the poor.  Despite a constitutional requirement that presidential candidates had to be born in Honduras, he managed to be elected President of Honduras in 2002 on a platform of fighting crime.  He initiated the "Illicit Association Crime" law that put hundreds of gang members behind bars.   He also did some educational and financial reforms that benefitted the poor.   While he was in office, he met and married his second wife, a Spaniard, Agua Santas Ocaña Navarro.  He said she gave money to every beggar she saw and because of her they took in 12 street children during his presidency. Most were badly malnourished, so his wife nursed them back to health and then sent them to boarding school in Spain.  They all thrived and are either in universities or graduated and working.  He and Agua Santas divorced after he left office as she "couldn't get along with my kids from my first marriage," and she moved to Nicaragua with the remaining adopted street kids and formed a foundation for children.  In 2006, he lost re-election and since then has mainly devoted his time to his  foundation, Inversions la Paz and to the Fundación para la Educacion Ricardo Ernesto Madura Andreu, named for his son. He also supports various organizations such as Operation Smile.  Amazing.

We returned to the hotel and this evening had our pre-surgical meeting.  The pediatric intensivist arrived and I am, happily, no longer the team doctor.  Tomorrow morning, Jen and I and four nurses will have a quick breakfast at 5:45 and leave the hotel at 6:00 so that we can have the first two groups of patients ready for surgery at 7:00.  The first day of the surgical week often starts at 7:30 instead of 7:00, but at least the patients will be ready.  Kara bought two boxes of chocolates which I'll present to the local nurses along with a  "speech of gratitude for hosting us" tomorrow morning.  Thus will begin our campaign of winning them over!

Day Three - OR setup and Clinic Visit 2/20/16

This morning, a small group went to the screening area where the patients had gathered to find out if they would be having surgery.  I had left the scheduling meeting after the charts had been reviewed, but the team leaders, Michael, surgery, Mercedes, anesthesia and the Clinical Coordinator, Yazan stayed to do the boards, the large tagboards, one for each day that have slips of paper for each patients taped up into time slots for the six operating room tables.  Apparently, new disagreements arose, likely in part due to the fatigue of the hour, and in the end, Yazan decided to limit the number of palates per table per day and to have no palates on Thursday.  This drastically reduced the number of cases, making the Honduran representatives very unhappy.  This morning, the "for sure" patients were told "yes," a small group was told, "no," but another large group was told, "maybe."  The decision was made to do the OR setup, have lunch and then tackle the scheduling again.

I was blissfully unaware of this controversy as we drove to the hospital after breakfast.  Although it's old, it was built in that beautiful style I've seen before in Latin America, all open courtyards and wide walkways and lush plantings.  Sally, who's been here before had a warning: be careful on those beautiful black and white tiled walkways after mopping or rain. Apparently they becme like black ice.  Before we could go to the ward, everyone was needed to unload crates and boxes of equipment and medications for setting up the OR's.  three nurses and I took on the task of reviewing the three "crash boxes." These are very similar to fishing tackle boxes and house the emergency drugs.  There's a very long list of what should be in  them in terms of medication and equipment, so we spent about an hour and a half making sure each box had what it needed, weeding out the expired medications and replacing them with new vials.

 Finally we got the go ahead to explore the wards.  Post op is the women's ward and there were still two patients there.  We were able to walk around a bit, but got no response from the three nurses at the nursing station to our very cheery greetings.   We did get what I think might be called the "stink eye," from at least one nurse - a first for me.  Tomorrow, on team day, I'll be searching for an extra big box of candy to give to the nurses on Monday. This will start my Dr. Bartlett's tried and true method for overcoming hostility of and encouraging cooperation by the ward nurses.  

#1.  Bring a large box of candy and present it to the head nurse with introductions of myself and the OpSmile nursing team and effusive expressions of gratitude for allowing us to share their ward.
#2.  Be pro active in stripping the sheets and putting on clean ones after patients are discharged.
#3.  Find out where the brooms are kept and help sweep the ward between surgery days.  Empty the trash cans when needed.
#4.  Pick up or clean up bodily waste if you see it on the floor.

Initially, steps 2-4 might be seen as demeaning and lower your status - doctors should not stoop to doing menial tasks.  However, if you persist in working side-by-side at these shared chores, you will end up being seen as a "regular person" as well as a respected doctor.  As a final gesture, I always ask the PC to order a cake for the last day.  The next team that comes to the hospital will find the nurses much more receptive.

We continued our explorations, but the pre-op ward, which is actually a little closer to the OR, had just been mopped so we were not able to see it at all. Tomorrow, after our team day, we have a 5:00pm pre-surgical meeting at the hotel. When that's done, Sally, Maria, Monika and I (pre/post nurses) will go over and check the kids who will be having surgery on Monday and do some set-up of the wards.

When we were done at the hospital, Kara, the program director, asked me to come to the Op Smile Clinic to see a couple of kids who were scheduled for Monday and whose parents were worried about coughs.  I hadn't been to the clinic before and hadn't realized what an amazing place it is. It was built with money from some companies in Japan in 2006 and provides first class cleft lip and palate care for kids in Honduras.  They have two operating rooms where they do cleft lip surgery, a recovery room and other rooms for dentistry, speech and audiology, nutrition and psychology.  After I examined the kids, who were fine, I noticed that Kara was on the phone with Glenn, the pediatric intensivist who is still in Denver and will be arriving tomorrow.  She was explaining about the conflict about palates and trying to get his opinion. I asked if I could speak with him and explained the dilemma  as diplomatically as I could. He asked my opinion, and I told him that solely from a pediatrician's point of view, and after listening to Michael, I felt that the team could handle more palates and that certainly the nurses could handle more. He and I turned out to be on the same page in that we both are used to coming in early and leaving after the last patient is stable, letting the nurses go back  to the hotel rather than asking them to stay.  He talked to Yazan and Michael, and suddenly, everyone relaxed and the disagreements disappeared. They put back in all the palates and started calling parents who had been sent home.  They called Mercedes at the hotel as she needs to sign off on this as well, and she just said she was fine with whatever they wanted to do.  So now we will have very long days but we will get the surgery done on all these kids, including the 22 year old, and it will be worth having come on this mission.

Tomorrow is team day and we are going to Valle de Angeles, a small tourist town about half an hour from here. There's a volunteer with a house with a pool who has invited the team to lunch.  More about the day tomorrow.
I've posted some photos of the hospital and clinic.

Screening Day Two and selection of Patients for Surgery - February 19

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.