The First Day of Surgery-Ghana

I’ve just completed day one of surgery on this mission.  We are scheduled to have four full days of surgery and then a half day on Saturday.  There are seven tables, two are for teaching and therefore will go a bit more slowly, and the last table is for cases that can be done under local anesthetic.  All the surgeons rotate doing the “local” table; some love it and others would much rather have the patient asleep.  The “half day” on Friday may be more like a 2/3 day as there are lots of patients, many of whom have traveled great distances to get here.  We’ve seen quite a few patients from Togo, the small African country, not the island.  Its border is only about 8 hours from Ho, and there are no cleft surgeons in Togo.

On Monday, Kathy, a pre-op nurse and I went to the hospital at 5:50 am -  about 45 minutes ahead of the rest of the team - so that we could get the first two rows of patients ready for the surgeons.  The night nurses had done a great job with hydration, waking the patients every two hours to give them dilute juice.  Many parents don’t want to wake their babies for fluids and then deal with getting them back to sleep, (never wake a sleeping baby.) It takes a skilled, determined nurse to get 37 babies, toddlers, kids and adults awake enough to drink dilute juice three times between midnight and 6:00 am and remain cheerful about it.  If you don’t maintain hydration in this heat, especially in the babies, the anesthesiologist may not be able to start an IV and the surgery will be cancelled.  That was exactly what happened today to a one year old who is here to have her palate closed.  Ella, the local pediatrician who is a second-year pediatrics resident in her real life -  and I were called to the OR with the message that they “needed help.”  We ran over, fearing the worst.  A call to come to the OR usually means some catastrophe – cardiac arrest, massive hemorrhage or allergic reaction – where additional experienced hands are needed.  When we arrived, we found six people surrounding a baby who was asleep on the OR table.  The anesthesiologist was keeping her just under with inhaled anesthetic while two surgeons, two other anesthesiologists and the pediatric intensivist tried to get an IV going.  Ella and I joined in, each grabbing a limb while one of the surgeons started swabbing the groin and eight of us searched for veins, poked in IV catheters and tried to advance them, for another 40 minutes.  Someone shaved a patch of hair looking for a scalp vein and the surgeon tried to get into the femoral vein, a big vein in the groin.  We looked at her external jugular veins, but even they were not obvious enough to stab her there.  In the end, her surgery was cancelled.  If possible, we’ll try to get her on the Wednesday or Thursday schedule.  There were 39 patients on the schedule for Monday, including those on the “local” table.  Having this extra table where older kids and adults with lip clefts can have surgery with just local anesthetic, without added sedation, means that about 35-40 more patients will have surgery this week.  If we had to tie up an anesthesiologist and allow for time for the patients to be “put to sleep, awakened and “recovered” in the recovery room, the number would be cut in half.  The fact that these patients are willing to undergo this surgery with just shots of lidocaine into their faces shows how desperate they are.

The first day is always long because both the OR and the ward staff run a “mock code” so everyone knows what to do if a child had a serious event – respiratory or cardiac arrest, severe bleeding, serious allergic reaction.  It’s my job to do this for the ward, and it includes going over the “crash box” that has all the emergency drugs, making sure they’re all there, and reviewing the roles of the team members.  In an emergency, the child is moved to the “crash bed” by the nurses station where oxygen, the crash box, defibrillator and all other necessary items for disaster are kept.  A child can also go to this bed just for close observation for breathing difficulty or more than mild bleeding after surgery. Because of these “last details for the first day of surgery,” the surgeries on the first patients usually don’t begin until around 9:00, an hour and a half later than on subsequent days.  This, of course means the day will end later.  The last patient arrived on the ward at 10:30 tonight and we were back at the hotel at 11:30. Hans and Ella and I decided to divide up the late nights – an amazing luxury that I’ve never before experienced. I took the first night, Ella will stay on Tuesday and Hans on Wednesday. On Thursday, I’ll stay again.

One of the early kids to come to post-op this morning was an 18 month old palate patient. His oxygen level was slightly low at 85%. As soon as his mother put him down on the bed, his oxygen dropped to 70%, he woke up and began thrashing about, kicking and screaming.  In one of those unfortunate coincidences, his Mom was not calm and helpful in a crisis but instead became an adult version of her child.  He, of course, followed her lead and was soon hysterical with an oxygen level of 60%.  We took him to our crash bed and opened the crash box and tried to get oxygen on him.  It was like trying to put a mask on an octopus.  He kept grabbing for his mother who would snatch him off the bed, wrap him in her arms and loudly plead with him not to die. Soon a crowd of parents and kids gathered around the bed calling out advice, encouragement and exhortations against death.  With the boy’s oxygen at 58%, I asked one of our burly male nurses to snatch him back from his mother and we ran him to the OR, handing him off to the intensivist to deal with.  A little sedation and lots of oxygen got him to 85%, and six hours later, he was back on the ward, breathing comfortably, but still only at 85%.  His O2 saturation dropped to 70% if we put him on his left side, though he had no change in respiratory rate or work. A chest X-ray showed a marked difference in the circulation of the two lungs with decreased blood flow to the left lung, an abnormality of right cardiac border, (you can tell I’m not a cardiologist,) and increased vasculature in the upper lobe, I think.  I don’t know what he has, but he needs an echocardiogram.  That makes nine patients I’ve seen in four days with major congenital heart disease.  The good news is that there are two excellent pediatric cardiologists in Ghana and we can refer the kids to them.  The bad news is that the echo machine at this hospital is broken and won’t be working while we are here.  Although the radiologists don’t usually read the films in Ghana, we asked for readings on these eight incredibly abnormal X-rays, hoping to get some clues. Alas, I fear the lack of reading practice has taken its toll.  All the readings were the same: “enlarged heart, needs echocardiogram.”  The one we put on a diuretic for congestive heart failure had an addendum: “congestive heart failure.”
 Working with two other pediatricians makes a huge difference.  This mission is very big and complex, which makes for lots of time-consuming extra work.  In addition to managing the surgical patients, every day there are children and adults who need to be seen for illness. Most are parents or siblings of the patients, and they are staying at the shelter, a motel-like residence where they are housed for the duration of the mission.  As one might expect, gastrointestinal illness has broken out, and in this heat, dehydration occurs rapidly, especially in malnourished babies.  We have rehydration packets and water to give them, but have run out and had to re-order three times now.  I’ve also seen seven patients with malaria and have started to be able to recognize the symptoms.  Ella, the pediatric resident, knows it well. She does a rapid screen and then gives the patient the medication from our stash.  The people here treat it like a bad cold and usually have had it in the past.

Hans, the pediatrician from Sweden is on his first mission.  He is one of those very kind, thoughtful, “old school” doctors that everyone would like to have for their own.  He’s had a bit of an adjustment to make to the shortcuts required by the pace on the mission.  For instance, when a child comes back to the ward from the OR, unless the child is unstable, the pediatrician takes the chart and writes orders for ibuprofen and acetaminophen before doing an exam. This is done so the nurse can go get the medication and give it right away.  All patients get an acetaminophen suppository in the OR at the start of surgery, and local anesthetic nerve blocks toward the end of surgery. However, as those are wearing off, the pain will kick in.  I’ve found, and have been taught by other Op Smile pediatricians, that a dose of ibuprofen on admission to the ward goes a long way toward providing pain coverage.  Hans, as a careful, thoughtful physician, would normally review the chart and examine the child and then determine what medications are needed. Prescribing formulaically goes against his medical principles.  Another time saving device I use is that once I’ve admitted a post-op patient, I partially fill out the discharge papers, leaving the discharge exam and signature line blank. I fill in pain medication doses, time and place for the follow-up appointment, and I check off the pre-printed boxes for lip or palate care and diet instructions.  When the surgeon discharges the patient, I fill in the exam and sign the page. This saves time when all 39 kids are discharged at the same time the pediatrician is trying to finish up the pre-op exams and round on the post-op patients with the surgeons.  The patients need to leave so we can ready the ward for the patients who will be arriving from the OR.  Hans is now following this protocol, but in the beginning, it felt very foreign to him to write anything on the discharge summary until the surgeon had officially discharged the child.  He looked at me after I explained the “partial fill-in,” and said, “but it says, “discharge” on the form right here!”  To his credit, he has quickly become comfortable with the shortcuts, realizing that they don’t involve falsifying records or recording exam results 24 hours before the exam. I clearly remember my own discomfort the first few missions.  I had to find a balance and a way to provide excellent pediatric care in a much more efficient and time-constrained manner than I was used to.

The actual surgeries went well today but finished very late. The next to the last patient had his palate repaired and had been on the ward only half an hour when he started bleeding heavily.  For minor bleeding, the nurses or pediatrician can put pressure on the palate with gauze or have the child rinse with ice water.  We occasionally put various clot enhancing substances on the bleeding spot as well.  This child, however, was beyond all that. We called the surgeon down and after clearing out a bunch of clots, he soaked a piece of gauze in lidocaine with epinephrine (constricts the blood vessels,) and held it against the palate for 15 minutes.  The child started out protesting but finally fell asleep with the surgeon’s finger in this mouth.  The surgeon seemed surprised that the bleeding stopped as he was thinking he would be taking the child back to the OR.

A final anecdote before bed.  As I was walking down the outside corridor this morning on my way to the storeroom, I passed by a group of kids, age about 8-10 who were siblings of our patients.  They were playing dodge ball with two 8” diameter beach balls brought by the Child Life specialist.  As the days's discharged patients filed by, the boys stopped their game, the 10 year old  tucking one of the balls under his arm to give high fives to the departing kids. One of the departing mothers who had a baby on her back, grabbed the ball out of the boy’s hands and said to him, “I need this ball more than you do,” and walked off to the bus with it.  I was appalled but not actually surprised.  The people here have so little that putting kids first doesn’t always happen.  That’s it for today. Tomorrow we’ll come early again and Hans will join us.

Announcement Day

Before I get into a description of this long, long and unique day, I want to let you all know that I have finally solved my WIFI problems. The computer was hooked up with the hotel's WIFI and therefore my mobile WIFI wouldn't connect. I took everything to the hospital today, and in a free minute (HA!) I connected the WIFI and it went through. When I opened things up back here at the hotel, the connection had stuck and I was able to delete the hotel WIFI. So, barring further tech events, I should be able to blog and put up photos.

So, a few words about the photos: I have posted a new batch but without labels as I'm trying to catch up. If you click the link I sent you, you come to the page on OneDrive. Just wait and the album will come up. If you click on photos or something else, you may just get one photo, not the whole album.
There are photos there from the hotel in Accra. I had a huge suite. There was a big festival for the first lady of Ghana who was there all day doing various programs on empowerment of girls. There are a couple of photos of drummers and dancers - fast moving and blurry.  There's a photo of a wayside "women's toilet" on the drive to Ho. Most of decided we could wait.  I saw a baby with very low oxygen and there's a picture of his fingers showing clubbing, a sign of chronic pulmonary disease.  The pre and post op wards are shown with mattresses on the floor and a stack of extra mattresses by the wall. At least the babies won't be falling out of bed.  Most of the food in the restaurant is very western - spaghetti, pizza, rice, french fries.  However, one night there was a dish made of cassava and fine cornmeal made into a kind of paste and served with a really hot pepper sauce. There's a photo of patient washcloths hanging out to dry and one of "the walk of death." This is a pathway on the edge of the lawn where we screened patients and had the announcement day today.  It has small rocks and a border of big rocks that get kicked in among the small ones.  It's almost impossible to walk down the whole path without tripping, hence the team's name for it. Finally, there are some photos of Ghanaian women and their babies and a mother daughter pair, each with a baby on her back.

So, announcement day here is orchestrated to make the disappointment of not being chosen for surgery a little easier to take. Each of these patients meets with the surgeon who explains why they won't have surgery and answers all questions.  If they want to meet with the pediatrician, they do that as well. Then the coordinators meet with them and arrange their next mission visit.  it took until 3:30 in the afternoon to get through them all, and then we had to see all the ones who are having surgery, get their special wristbands on and admit the ones who will have surgery tomorrow. In addition, I'm still the team doctor and several team members needed minor but time-consuming attention.  There were also seven sick kids who needed prescriptions written, labs ordered, etc.  The other pediatricians had been sent back to the hotel by one of the (misinformed) coordinators who thought we were done, so it became a very long day.  The last sick child was very sick and ended up having to be admitted to the hospital. We arrived back at the hotel at 7:45 and had our pre-surgical meeting at 8:00. Tomorrow morning the team will leave the hotel at 6:30 but one of the nurses and I will leave at 5:50 so we can get the first two rows of kids ready for the six tables.  There are 167 kids and adults scheduled for the week - ambitious.
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Second and Final day of screening

Second and Final day of Screening-April 22, 2017

This was a generally frustrating and difficult day, starting with the lack of WIFI at the hotel and continuing with some sad medical diagnoses. The IT nightmare is complicated because the personal WIFI unit I rented for this mission isn't functioning.  I’m not able to email support at the company as I don’t have email.  The hotel internet is “present but not functional.” It has attached to my laptop’s WIFI but is not providing service for either the laptop or the phone.  Because it’s there, I can’t use the personal hotspot on my phone.  I wouldn’t want to use it long, but I was hoping to turn it on long enough to send my long-suffering husband an email letting him know I hadn’t fallen off a cliff.  In the end, I used a team member’s phone to send my message, and soon one of the IT guys from the team is coming over to take a look at my computer and phone and the WIFI thing.  It’s amazing how disconnected I feel being so far away from home and unable to talk with anyone in my family or to check the news.  If this were a planned wilderness camping trip sans electronics, it might have been very relaxing.  As it is, I’m stressed !!

The medical part of the day started with me in my continuing role as Team Doctor.  Thank goodness the Ped Intensivist, to whom this job belongs, is arriving tonight.  Yesterday, a nurse came to see me with fever, chills, headache and abdominal pain. Her rapid Malaria screening test (yes, there is one,) was positive and she is now on treatment and starting to improve.  Today the man who does medical records, the one who chose not to take malaria pills on the Ghana mission, (Ghana, practically the center of malaria’s universe,) came down with the same symptoms and, indeed, the same positive test. Two for Two.  Back in my pediatrician role, I saw a two year old boy with diarrhea for 2 ½  weeks.  After much prying, I learned that he had been treated for malaria three weeks ago and that the drugs that treat malaria often cause vomiting, diarrhea and cramps for weeks.  I also handed out Maalox and Pepcid from the kit to a nurse with heartburn, and Tylenol for headaches, likely brought on by mild dehydration.  It’s a challenge to drink enough water to keep up with the heat.
I guess I’ve been trying to avoid writing about today’s patients, but I can’t babble on forever. Yesterday I wrote a bit in the blog about the three babies with heart murmurs.  Only one was hypoxic (low oxygen,) but all three had significantly enlarged hearts on X-ray.  They’ll have their Echocardiograms on Monday.  Today I rechecked the baby whom I started on a diuretic for his  early  heart failure.  He’s much improved with a normal size liver and slower breathing.  However, I saw three more babies today with serious heart defects. None of the mothers had been told there was any problem other than a cleft lip. One baby is four months old and is still at birth weight.  His mother says she nurses him and then gives formula and he’s a great eater.  However, his oxygen is very low, and I think he just can’t keep up with his caloric needs.  He also appears to have glaucoma.  The second baby was 18 months old and has a normal twin sister who was on Mom’s back.  The boy had a cleft lip and palate, and his mother was very excited about finally having him look “more normal when I take them out together.”  He was so blue!  He had a very quiet murmur but a huge heart on his X-ray.  His oxygen saturation was only 60% (normal 95-100.)  He had the most impressive clubbing, an abnormal swelling of the bases of the fingernails, that I have ever seen.  Finally, I saw a 2 ½ month old baby with multiple problems.  I think the baby has Trisomy 13, a syndrome in which about 70 % of the babies live less than a year. This baby had very low oxygen, a long loud murmur, extra fingers, dislocated hips and bilateral microphthalmia, very small poorly formed eyes.  Although his mother had brought all his records with her, including his cardiac Echo, his X-rays and specialist reports, she had no idea about the results of his tests.  She was tearful and said that each doctor would see one part of her son and say there was nothing to do. The eye doctor, Mom said, told her, “Your son is blind so good-bye.” Her question to me was, “If my son can’ t see well, why isn’t the doctor helping him?” Since there were two other pediatricians there for screening, I spent the next hour with her, trying to explain his medical problems and to answer her questions.  Although she left with a much clearer idea of her son’s situation, and seemed grateful, we were both profoundly sad.  Her final comment was that she had hoped that he would be able to walk.  Even in the face of this devastating condition, parents have such strong hopes for their children.  Each of these parents, the four yesterday and three today, came here hoping for a new face for their child.  Instead they have learned that their child has a much bigger problem, hidden though it is.  We won’t know until the ECHO’s are what the magnitude of the problems are, and whether they can be fixed, but I expect, given where we are that prospects will be limited.
So briefly, we screened 280 children and adults and tomorrow the team will announce who is on the schedule and will meet with those who are not to set up next steps and next missions. It’s bound to be difficult.  I don’t think I’m in on that part of it, so I’ll likely be helping to set up the wards. We don’t have an official team day this mission, but there’s a “Make your own Batik” session tomorrow that I’ll likely skip.

First Day of Screening

First Day of Screening, April 21, 2017

Today was the first of our two screening days.  There are about 300 patients in the shelter from as far away as 12 hours by bus.  A woman named Sabrina and her husband were on a motorcycle trip around Ghana a couple of years ago and came across an Op Smile mission.  They asked if they could help, and ended up playing with patients, unloading cargo and visiting with parents while their kids were in surgery. They were so taken with the whole event that they decided to stay in Ghana and join the Op Smile Ghana organization.  Their main job is to scour the countryside on their Harleys, searching out infants, children and adults with clefts and telling them about Op Smile.  They then arrange busses at pick-up points the day before screening to bring the patients to the shelter.  As you might expect with someone doing that work, they are both incredibly exuberant, energetic people.

The screening was conducted at the hospital where the surgeries will take place next week.  As usual, pediatrics and anesthesia joined together to screen patients. Usually a pediatrician and an anesthesiologist see each child, but since there are three pediatricians, Hans, a first time volunteer from Sweden, Ella, a second year pediatrics resident from Ghana, and me. (the pediatric intensivist won’t be here until Monday,) and nine anesthesiologists, the six “extra” anesthesiologists paired up and saw older kids and adults.  Any patient five and under was seen by the pediatricians.  Hans watched me do one patient and was then off on his own with an anesthesiologist, though because we are all together in one room, we often ask each other to have a look at a child we are screening.  This made it easy for Hans to be independent but also have backup if he needed it.  Ella is extremely experienced and a great pediatrician. She has to finish her residency before she can be credentialed, but I’ll sign her Op Smile credentials at the end of the week.

There were two kids with acute malaria at screening today, and both the parents and Ella were very calm about it.  One mother had had malaria herself about a month ago, and both expected that the high fever and achiness their children were complaining of would turn out to be malaria.  Ella arranged the prescriptions and off they went. The Pedi Intensivist acts as the doctor for any team member who is taken ill on the mission.  Since he isn’t here yet, I get to play Team doctor until he arrives. One of the nurses came to me saying, “I think I have malaria again.”  We did her rapid test right in the screening room, and it was positive.  Ella arranged her meds as well.  I ruled out scabies and chicken pox in a couple of patients and handed out bacitracin for some superficial skin infections.  I’ll be glad when the real team doctor arrives.

Today was fascinating, (medically,) due to the “extra-cleft” diagnoses.  Within the first hour of screening, I saw three babies with cyanotic heart disease.  One was a four month old with an oxygen saturation in the low 80’s, a loud long murmur and a weight just 500 grams above his birth weight.  His liver was big and his breathing fast.  His chest X-ray was rotated (not straight on,) so it was hard to say much about it except that his heart is huge and globular.  After discussion with Ella and the pediatric anesthesiologist, I started him on a little diuretic to see if he can eat more easily.  Two other babies had big murmurs but oxygen saturations in the low 90’s and normal livers.  They also had big hearts, one with a wide mediastinum and the other not.  They’ll have Echocardiograms on Monday and then we’ll try to get them appointments with one of the two pediatric cardiologists in the country for next week.😝😝  I also examined a baby with microcephally and spasticity in addition to her cleft lip.  Her disabilities may well be due to the ZIKA virus. Finally, I saw a nine-month old who weighed 4 kg at birth and now weighs 4.9 kg.  He’s grown pretty well in height, but is very scrawny.  I watched him nurse and he did fine.  It took a bit of careful, gentle questioning through an interpreter, but I found that Mom is only offering the breast three times a day.  As I was finishing my exam of the baby, I went over to discuss this baby with one of the surgeons whom I knew from previous missions.  He's not only great technically, but I knew he was always careful to consider each child's circumstances fully.  I found him in the midst of an argument with the rest of the group who wanted to postpone this baby’s surgery to give him time to gain weight.  He felt strongly that they should put the baby on the schedule now because he thought the infrequent feeding was due to the mother's embarrassment by the baby’s appearance.  He argued that fixing the baby’s lip make him more acceptable and the mother will be open to feeding more.  More importantly, he’s afraid that if we don’t fix the lip, the child will continue to waste away.

Tomorrow we screen the second 150 and on Saturday night, make up the surgery schedule.  Sunday is devoted to telling the parents whose children were not chosen, explaining why and setting up their appointments for the next mission.  Some are straight forward – too young or poorly nourished, the babies with the heart defects that need attention and kids who are acutely ill.  Some, however will miss the cut by chance as there are more qualified patients than there are spots on the schedule.  Just like in Madagascar, here in Ghana there is a huge backlog of untreated patients.  These training missions are designed to address that problem but will take some time.

Day Two: Ho, Ghana

I set my alarm for 5:45 to give myself plenty of time to finish packing and get my suitcases down four flights of stairs and out to the parking lot before breakfast at 6:30. Starting at midnight, I woke every half hour in a panic that I’d slept through the alarm.  I finally gave up at 5:00, exhausted from the up and down and clock-checking.  I don’t know if it’s the Malarone for malaria prophylaxis or just my craziness, but it was a bizarre night.

The drive from Accra to Ho took about four hours on narrow rocky roads. We passed through many small communities with plywood houses and roadside stands selling mangos, pineapple, bread and beaded jewelry.  I rode next to Henry, an Op Smile Ghana board member since it’s inception in 2011.  He’s also a member of the Lions’ Club and when Op Smile Ghana formed, the Lions’ Club partnered with them and continues to raise money to support missions.  Henry told me that for the 25 million residents of Ghana, there are just 3500 physicians and 200 dentists.  Medical and dental education are subsidized in Ghana, and students come from all over Africa for the free education.  Most of the young physicians, however, leave the country to practice.  Those who stay generally specialize and practice in the cities.

Another factor contributing  to the shortage has been the EU.  Since English is the official language of Ghana, large numbers of the young doctors go to the UK after graduation.  With England pulling out of the EU, that avenue may close, and with Trump tightening immigration, the other big path out of Ghana may be closing as well.  The Ministry of Health is not counting on the doctors staying and is looking at developing a program to train medical assistants to be the “doctors” for the rural areas of the country.

Sitting behind me on the bus was a lovely woman who is an OR nurse.  I really enjoy her; I’ve worked with her on a couple of past missions.  However, she is one of those non-stop talkers and managed to keep up a monologue for the entire four-hour trip.  In addition, her laugh, which punctuated her monologue every few minutes is a dead ringer for the laugh of Dustin Hoffman’s character, Mrs. Doubtfire. If you don’t remember it, I’m sure you can find it on Demand.
We were booked into a beautiful hotel overlooking Ho, but when we arrived, we found that the President of Ghana and his entourage had arrived that day unannounced and had taken about half the rooms.  Half the team is now at another hotel about 30 minutes away.  I’m one of the lucky ones with a room here; the others will have to move back once the President moves on.
We went to see the hospital today and it’s built in the open-air style that is also common in Latin America.  Tomorrow and Saturday we will screen about 400 patients and then will have to choose only about 125 of them for surgery.   However, by the end of the week, each resident will have done lips and palates from start to finish and at least two or three will be accredited.

April 19, 2017 - first day in Ghana

I’ve arrived in Accra (Ac-CRÁH,) the capital of Ghana, and will stay overnight with several team members before driving on to Ho tomorrow. We’ll leave right after an early breakfast and drive for 3-5 hours, depending on traffic and road conditions, i.e. washouts, rock falls, ruts, herds of goats.  I met up with another Op Smile team member at the Logan airport, and thought I had worked with her before.  I greeted her with a smile and a hug, which she returned, Op Smile style.  She then told me I had never worked with her; in fact, we had never met at all; I was a TOTAL stranger to her. She was obviously enjoying the whole scenario.   I had worked twice with her identical twin sister who also volunteers with Op Smile!  I was truly amazed.  She said that she and her sister go to the big twin convention in Twins-burg, Ohio every year and that last year they came in second in the “most identical” competition.  It made me feel a bit better about mistaking her for her sister.  The flight from Logan to JFK was short and easy, and after a three - hour layover, we boarded the plane for Accra. I had paid a bit more to have some extra leg room, but the man in front of me immediately put his seat back as far as it would go and laid his head in my lap. For the next 13 ½ hours, he snored away, skipping drinks and dinner while I wrestled with my conscience, managing to resist the extremely strong temptation to dump ice water over his head.

Meanwhile, in the row behind me, a 3 year old boy and his grandmother waged an epic battle over a video game toy.  The grandma was in a fury, screaming at the boy, telling him he would never ever be able to get it right, his mother should never have bought it for him and he should just SHUT UP and quit whining.  The boy, from what I could tell, was enjoying playing the game his own way, but the Grandma wanted him to play it “properly."  The only whining I heard was from the Grandma. She periodically raised her hand as though she would strike him, and repeatedly called him a “devil-child.” He, of course, responded to all this abuse by crying more loudly, and she ended the interaction by taking the toy and putting it in the overhead bin until he could “grow up and follow the rules.”  An Op Smile team member was sitting across the aisle from the grandmother and finally couldn’t take any more.  She said, firmly, “don’t you hit him.”  The grandmother didn’t miss a beat responding, “stay out of it.” They went back and forth several times, “don’t you hit him,” “mind your own business,” while the poor little guy kept crying. Finally, he wore himself out and fell asleep.
I was reminded of times in my office, before I retired, when I would see a young child whose parents were having a hard time with normal but difficult behavior.  I never observed this degree of verbal abuse, but there were times when it was clear that the message the child was receiving was that he or she was bad.  It always made me so sad, knowing that the child would likely grow up feeling that he was bad, unlovable, somehow defective. I just wanted to snatch this boy up and cuddle him and disappear the grandmother.  Likely I’d have ended up in a Ghanaian jail. One  of the things I love about Op Smile trips is observing the different cultures and styles of parenting.  I hope the remainder of my time here is filled with positive parent child interactions.

We’re staying at the Coconut Grove Hotel here in Accra.  The First Lady of Accra is here all day for a conference on empowering girls. I haven’t seen her, but there are dignitaries everywhere and many,  many uniformed soldiers carrying multi-weaponry.  The hotel is very fancy, and I have a “suite.” Luckily there is AC as it’s 95 degrees and 66% humidity. This afternoon, three of us shared a taxi to the local craft market.  It turned out to be a bit stressful.  The taxi driver was a young man from the neighborhood where the market is, and he’d only been driving a taxi for about a month.  He was obviously very excited about taking us there and escorting us through it.  He was so busy explaining the market and the bargaining process that he didn’t watch where he was going and got lost.  Suddenly we were in the middle of the town dump, the car surrounded by about 15 young men and boys whose impromptu soccer game we had driven into.  While I sat there imagining, “bad outcomes,” the young driver started joking with the soccer players.  It seems they were his schoolmates and were teasing him about taking tourists to the dump.  He finally got us to the market, a warehouse-type building filled with tiny cubicles and competing artisans. I bought some small paintings of Ghanaian people done by a young man, and I was done.  Getting out of the market, however was nearly impossible.
Artisan: Miss, come look at my……..
Me: “Oh, no thank you. I’m done buying.”
Artisan: “Oh, I know you’re done spending money, just come look to give me luck.”
Me: (after SEVERAL rounds of me firmly stating I’m DONE!!,) “I’ve spent more than I should have. I must buy my food all week. I think I’m going to be very hungry.”
Artisan: “Oh I know you aren’t buying anything else, Catherine, - yes, by now they knew my name – if you just come look at what I have in my space, I’m sure you’ll bring me luck and the next person will buy something from me.”….  then, in the stall, “See this tiny bracelet or ???, only $15 just for you because I know you are done buying things today!"

The final blow came when we arrived back at the hotel.  The driver had given us a reasonable rate for our trip to the market and back, and we had discussed that since I was in the front and had US dollars  preferred by all the locals, I would pay him and the other two women would reimburse me.  However, they both forgot and both paid him as they got out of the car.  Unaware that the young man had already received twice the quoted fare, I handed over the cash for all three of us!!!  He smiled sweetly, took the money and drove off.  I’m trying to consider it my good deed for the day, trying really hard.

This mission is an official teaching mission.  Op Smile is always teaching, but in some countries, like Ghana, where there is a big need and very few qualified, trained surgeons, they put on formal teaching missions to try to quickly build up the number of competent cleft surgeons, nurses, anesthesiologists,  and nurse anesthetists. Of the six operating tables two will be teaching tables and will have five residents each and two plastic surgeons.  Cases will be chosen for their teaching quality at those tables and they will necessarily go slower.  It will affect the total number of cases we can do, but is desperately needed. The population of Ghana is 25 million, and there are only two plastic surgeons in the country who have ever repaired clefts. They were trained by Op Smile last year.  There are ten plastic surgeons total in m Ghana.  By the end of this mission, there will be four qualified, accredited cleft surgeons and by the end of the year, another two. Gradually over the next year, more and more will be trained. Anesthesia residents are also being trained.  I will be training two pediatric residents, and there is a first-time pediatrician from Sweden on the mission.  He’s 70 and a friend got him interested!

This is long enough so I’m going to stop, but I do have one quick story.  One of the surgeons arrived yesterday, and at breakfast this morning at the hotel, a man came up to him and remarked on the Op Smile tee shirt he was wearing.  The surgeon explained what he would be doing in the coming week and the man became tearful.  He said he had a 6 year old daughter with a cleft lip and he didn’t know it could be fixed.  The surgeon told him to get up to Ho on Monday morning early and by the end of the week, his daughter would have a beautiful new smile. The man was at the hotel for a conference, and he jumped up, leaving his breakfast, ran up to pack his things and checked out.  I expect I’ll see him and his daughter on Friday.
I’ve posted some photos of the hotel, the band and some dancers - artistically blurred. On One-drive. The band and dancers were part of the First lady’s celebration.

On My Way to Ghana

On April 18th I'll be flying off to Ghana for my 18th mission with Operation Smile.  The team is big due to an unusually large number of observers and trainees.  There are 92 members, mainly comprised of Ghanaians with with five from Sweden and two to three each from Israel, Egypt, Kenya, Spain, Belgium, Brazil, South Africa and China.  The chief cleft surgeon and Team Leader is from Ghana.  There are six surgical residents and three anesthesia residents on the team.  They will be observing and assisting in the same capacity they would in the OR in their home countries.  There are also four CRNA's (certified registered nurse anesthetist) observers from Ghana on the team, an orthodontist/dentist observer, and four nurse observers. There are also eight trainees in areas such as medical records, Patient Imaging and Biomedical Technician, (keeps all the medical equipment running and "Macgyvers" -  what is needed in less well-wired countries. There is an extra surgeon, anesthesiologist, Biomed and Patient Imager to provide education.  Patient Imaging or photography, is actually very complex.  Each child has "before" photos, intra-operative photos that are very precise and may be used to guide subsequent surgeries.  Immediate and two week post-op photos are also taken.  All of the photos are archived for use in the education of local cleft surgeons.
There are five students who have been active in developing Op Smile student support clubs at their schools and have thus qualified to join a mission. They have a student sponsor who travels with them.  They each try to find a patient close to their age and follow him or her through the surgical process. They also do a project like helping out at an orphanage while they are in the country.  Finally, there are eight guests and their Op Smile sponsor. I think the guests on this mission are from Sweden and likely are sponsors for this trip.  Sometimes the guests are well-known celebrities in their countries and do filming for money-raising back home.  So, subtracting out all the "extras,"the number of team members involved in the actual patient care comes to 41 plus the residents (10) - 51 - as they both learn and help.

I'll be doing photos a little differently this time - I hope better.  It's on OneDrive and I'll email the link. It only has one public domain photo from Wikipedia right now.
   More later