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.
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.
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