Final Days

Thursday was the final full day of surgery, and Friday was a half day.  Both were packed full as the surgeons tried to fit in as many of the remaining patients on the waiting list as possible.  All the residents completed one palate and two lip repairs as the lead surgeon with the credentialed Op Smile surgeon assisting, and the anesthesia residents all had the opportunity to manage general and local anesthesia and perform the various blocks under the careful supervision of the team anesthesiologists.  On the wards, the nurse trainees from Ghana were amazing.  They all work as hospital nurses in Ghana, so their general nursing skills are solid.  To be credentialed for Op Smile, they needed to learn about the special needs of post-op cleft lip and palate patients.  This includes getting oral fluids in without disrupting their sutures, managing any post-op bleeding from the palate, recognizing and treating breathing problems from airway irritation, bronchospasm or excess secretions.  Finally, they learned how to do the discharge teaching about wound care, medications and feeding, and each had a turn presenting this information to the parents.

The parents were very supportive of their young professional countrymen, cheering them on, sometimes teasing, but generally trying to make sure they were comfortable and would succeed in their credentialing.  On Friday morning, while I was signing the discharges, it was the turn of a rather soft-spoken nurse trainee to give the discharge spiel to the parents. One of the mothers took her aside and said, “You got to shout out those instructions, girl, if you want to pass.  None of that mumbly stuff you usually do.”  Though she didn’t exactly shout, the nurse did speak up enough that there were no complaints about not hearing her.

I took Thursday night late call and the last patient didn’t reach the ward until 10:00. The PI had been treating him for post-extubation bronchospasm in the recovery room for two hours, alternating albuterol and terbutaline updrafts, IV steroids and 6 liters of nasal oxygen.  He’d also given the boy Benadryl to sedate him as he had been thrashing about on the bed. Unfortunately, as sometimes happens with children, the boy had become more agitated, pulling out his IV and trying to take off his oxygen.  When he arrived on the ward, he was asleep, thanks to some clonidine.  His IV and nasal prongs were heavily taped in place and his oxygen was being weaned.  I stayed around until it was clear he was out of the woods and then left for the hotel.

Friday morning Hans, Kathy and I were on the 5:50 bus to the hospital to prepare the final patients for surgery.  I’d gotten to bed at 2:00 so was not at my most perky.   Just as we finished the pre-ops, one of the medical records volunteers brought over a four year old boy for me to screen.  His parents had driven overnight, hoping to arrive in time for their son to be evaluated.  He didn’t have any clefts, but he had never spoken, and they thought maybe a tongue tie or other minor surgical problem might be the cause.  My heart sank as I listened to their story because I’d heard it several times before on Op Smile missions.  The child was deaf, likely profoundly so.  When I asked the parents about their son’s hearing, they replied that he could hear and understand everything.  But when I asked his mother to stand behind him and call his name and ask him to tell her his sister’s name, he didn’t respond at all.  The father understood before the mother, I think because he was sitting in front of his son and saw the complete lack of response to the mother’s voice. The mother even said, “He hears fine. He just needs to see me.” She paused then and you could see her processing her own words. When they both understood that their son could only “hear” them when he was lip-reading, we talked for a while.  There are no services, no formal signing, no hearing aids or cochlear implants for this child from rural Ghana.  On the other hand, their son seems very bright and has taught himself to lip-read well enough that even at four years he understands complex directions and all his extended family thinks he can hear.  The local Op Smile coordinators and Lions Club will work with the family to see what might be available for the child.

Friday afternoon was spent packing up and getting ready for the Team Party Friday night.  Usually the team party is a big event held either in the hotel where the team is staying or a nearby hotel if needed.  Dinner is followed by the presentation of certificates and speeches thanking the local sponsors.  The photographers on the teams usually make a slide show from photos they’ve taken during the week, including as many team members as possible.  Finally, local musicians play and there is dancing into the night.  This year, everything felt different.  The surgeon’s death still hung heavy over the group, the coordinators were still absent, and the unrelenting 12 hour days had everyone exhausted.  After the dinner, most people were ready to head to bed.  Some of the younger team members did go out to a dance hall with local volunteers from the team, but I was almost asleep at the dinner table.

On Saturday morning after we discharged the Friday patients, the team would be driving back to Accra, so we had to have our bags packed and in the lobby of the hotel before we went to the hospital.  Most of us were flying out of Accra about 10:00 pm, but a few had earlier flights.  The drive to Accra takes about 5 hours, so the plan was to leave the hotel at 9:00 am.   Dr. Ampomah, the Surgical Team Leader who is from Ghana, Kathy and I went over to discharge the patients, and some of the other team members came to pack up our remaining cargo and make sure we left the wards and OR’s clean.  The final count was 157 operations - about 40-50 more than the usual mission.  No wonder everyone is exhausted.  There is however, exhilaration that goes with knowing we were able to treat so many patients and send fewer home disappointed.  The patients will stay another few days at the shelter and then Dr. Ampomah, Ella and a local nurse will do a final post-op visit before the patients are transported to their home villages.

On the way out of Ho, we had a surprise stop at the shelter. The parents and patients were waiting outside for us with a thank you banner and a celebration song and dance that went on for about 45 minutes.  It’s hard for me to describe how moving it was.  People of all ages were singing, playing bells and drums, swirling and stomping and shaking, all the while moving in a huge circle around the open space in front of the shelter.  They all had small white cloths that they twirled above their heads.  Babies bounced along on their mothers’ backs and small children danced and sang, imitating their parents.  When the dance finally wound down, everyone mingled for another half hour, parents thanking us, asking about our homes, telling about their villages.  It was overwhelming.
For most of the parents and kids who come to an Op Smile mission for evaluation, it’s the first time they have seen another child with a cleft or met another parent in their situation.  The vast majority live remotely and think their child is the only one in the world to have been struck by this catastrophe.  When they come to a mission and stay in the shelter with, in this case, almost 400 families with children with clefts, everything changes.  They see other parents and begin to see themselves as more normal and their child’s clefts as a medical problem that can be corrected rather than a curse.  The children, who by age three are covering their mouths in public, are suddenly smiling and playing with others who look like they do.  Besides the physical healing, a lot of emotional healing takes place here.

I’m going to stop now. This blog has been disorganized and I apologize for that. Much has been written from notes rather than the same day due to my computer issues, so I’m sure I lost some information and spontaneity.  However, I also don’t want to ramble on too much.  When you go to the photos, the Ho Ghana album is where I’m working on arranging side by side pre and post op photos, but there are still some in “faces” and “crowd” photos as well.
Thank you for following my adventures.

Third Day of Surgery

I’ll start with a note about photos before I resume: Because of my WIFI blackout, I was unable to upload my photos all week. I’ve now put some up but they’re not organized, particularly the pre-op and post-op ones.  As soon as I have the blogs done, I’ll get the photos arranged.  Meanwhile, feel free to view them.  Some people have said they are having problems with the link.  I’ll check on that as well.  I’m sorry for all the glitches this time around.

I promised a few words about the pediatric intensivist on yesterday’s blog entry, but it was getting too long, so I’ll start there today.  On each Op Smile mission, there is a pediatrician who evaluates all the kids at screening, looking for health issues apart from the cleft and making sure the child’s nutritional status is sufficient for surgery.  That’s not to say the surgeons and anesthesiologists aren’t paying attention to the overall health of the patients; everyone is very picky about who goes to surgery.  However, it is specifically the pediatrician’s job to make sure at screening and again the morning of surgery that each patient is healthy.  Each child is examined the morning of surgery and the pediatrician reviews the last time they ate and drank, (NPO status,) vital signs and any pre-op bloodwork.  The pre-op nurses also review NPO status and reinforce the no eating rules to the parents throughout the day.  Here in Ghana, we didn’t have a single instance of a parent trying to feed a child before surgery.  In Latin America, it’s not uncommon to find a child on the way to the OR with “just a little rice” in his mouth.  The other part of the pediatrician’s job is post-op care.  As each child returns to the ward, he is examined by the pediatrician and post-op fluid and medication orders are written.  Breast-fed babies with lip surgery can go right to the breast; bottle fed babies use a syringe or cup.  Kids who have had palate surgery also use cup or syringe for their fluids and the IV’s come out as soon as it is clear the child is drinking.  With the temperature at 98-100 degrees and 65% humidity, fluid management this week was even more important than on other missions.  Throughout the day, the pediatrician and pre-op nurses check in with the CC who is at the master schedule in the OR to see which waiting patients can be hydrated.  Patients having their surgery later in the day may have to be hydrated four or five times.

So that’s the pediatrician’s job.  Every mission also has a Pediatric Intensivist.  Since they are pretty rare – only 500 in the US – that position is sometimes filled by a pediatric anesthesiologist.  The PI’s job is immediate post-op care in the recovery room.  Kids go there directly from the OR and stay until they are awake and stable enough to come to the ward.  He also takes care of any patient who develops problems with breathing or blood pressure during or after surgery.  The PI is also the Team Leader for pediatrics and is supposed to be available to the pediatrician and ward nurses for consultation on any problems and for teaching if there are “interesting cases.”  On my 18 missions, I have been lucky enough to have had 16 wonderful PI’s.  One other time, the PI was unhelpful, condescending and generally argumentative.  The PI on this mission was very difficult.  Normally, the PI comes to the ward each morning and meets with the pediatrician and nurses since he has no real duties until the first patient arrives in the recovery room.  Many PI’s help with the pre-op exams.  The PI on this mission didn’t arrive until the first day of surgery as he had other commitments.  Even though there were some difficult patients on the ward and I called over to the recovery room to speak with him, he was always busy and offered vague advice through the nurse.  When patients had complicated or long recovery room courses, he sent no notes or messages about them, leaving us in the dark about what we should watch for.  His biggest transgression, however, was that he was very rude to Ella, the pediatric resident from Ghana who was working with us.  She’s an excellent physician and very knowledgeable about malaria and other local diseases.  After one of our program coordinators left to deal with the death of our surgeon, the other became very ill with severe dehydration.  Ella was with her in the recovery room helping to start her IV and calculate fluids when the PI came in, changed all her orders, questioned the IV placement and told her he didn’t like “trainees” in his recovery room.  So, that’s enough about him except to say that it took me awhile to convince Ella that remarks made by jerks carry no weight and are best ignored and forgotten.

Hans and I met in the parking lot as usual at 5:50 this morning, but Kathy, the pre-op nurse didn’t show up.  When I called her room at 6:00, she was still in bed having been up all night with diarrhea.  Being the compulsive team player that she is, she came over to the pre-op ward about an hour later and stayed the whole day.  Meanwhile, Madison, our remaining program coordinator became suddenly ill and quickly became so dehydrated that she was hallucinating. The Clinical Coordinator, Brynn was looking for her and found her in the OR storeroom, sitting on the floor and mumbling about a man and woman in the corner who were drowning and she couldn’t save them and she was really trying but she was so tired…  The content of the hallucination likely had something to do with the surgeon having been found in the pool the day before, but the fact that she was hallucinating was alarming.  They got her into the PACU, put in a couple of IV’s and started hydrating her.  She’s better today after a few liters of fluid, back in her hotel room on her IV.  It’s a bit chaotic here.

Yesterday, when there were still six patients on operating tables at 7:00 pm, the surgeons moved the 6 remaining cases to today and put them first for this morning.  It means a longer day again today, but I don’t think there are any short days in the Ghana plan.  Ella’s patient with ectodermal dysplasia is back on the schedule after her labs were normal, as is the baby who was cancelled when no one could start an IV. To be sure she would be well-hydrated today, Ella put in an IV last night and the baby received IV fluids overnight.  Today is “Sports Day,” and I wore my youth football shirt.  A boy, slightly older and not so bold as the Superman fan, had his mother ask for the football shirt.  Since I still had the scrub top and knew I wouldn’t be wearing the football shirt again, it was easy to say “Yes” and save her son the drama of approaching me himself.

Despite the large number of patients, today went smoothly.  There was a 52 year old man who had NOMA (a severe “flesh-eating” type of infection seen in tropical areas that moves rapidly and destroys tissue,) at the left corner of his mouth and left cheek several years ago.  He had his repair today with a fantastic result.  There was also a 56 year old woman with a wide cleft who had a beautiful result.  Because their tissues and muscles have been in an abnormal position for so long, it takes more pulling and rearranging to repair some of the adult’s cleft lips.  After surgery they have considerably more pain than the children, and when their blocks wear off, they are relying on acetaminophen and ibuprofen – the only post-op drugs used by Op Smile for safety reasons.  The post-op photos often show the pain and not the joy, but if you ask them, they are ecstatic to finally have normal faces. 

One of the Ghanaian volunteers explained to us that in Ghana, most people in the remote villages assume that clefts are either the result of witchcraft or due to a very bad deed the mother committed during the pregnancy.  Most of the babies are killed, often ritually by burning to destroy any remnants of the witch.  If they are not killed, they may go through rituals involving fire to drive out the witch, and several of the children had scars from these rituals.  This volunteer explained that the children we were seeing on the mission were incredibly unique as they were from these rural villages but their parents had gone against the village leaders and kept them.  This meant they were shunned and the child had to be kept indoors or covered up if they took him outside. The child, of course couldn’t go to school.  As in other countries, once the cleft is fixed, the curse is lifted and the child and mother are returned to full village life.  I can’t even imagine being an adult with a cleft, trying to make your way here.

Ella and I left around 8:00 and Hans took over the ward.  The last patient arrived around 9:30 and Hans was back to the hotel by 10:00.  He did fine and it was great to be able to have an early evening.  When I got to my room, I put water in the kettle and plugged in in for tea.  About a minute later, there was a loud bang and flame and smoke shot up through the water and out the top, breaking the lid.  I unplugged the famous kettle and went to bed.

Second Day of Surgery

The plan for Tuesday, the second day of surgery was to start right on time and do 39 cases.  Kathy, Hans and I and Sheríff, one of the nurse observers met in the hotel parking lot at 5:50 am to catch the bus to the hospital.  Kathy made a remark about seeing someone swimming in the pool as she walked up from her room – some fitness fanatic, I think she said.  As we were finishing up the pre-op checks on the patients in the third row, one of the mission coordinators arrived. She was obviously upset and gathered us in the medicine room to tell us that the surgeon from Egypt, had been found dead in the pool.  Team members eating breakfast on the deck saw someone motionless in the pool below and ran down to pull him out.   Two anesthesiologists, both on their first Op Smile mission, and a couple of surgeons tried to resuscitate him, but he never had a pulse.  Portable AED’s (to shock the heart if someone has a cardiac arrest,) are now almost universally present in public places in the US.  At our hotel here in Ghana, they had no AED or emergency equipment, nothing but chest compressions and rescue breathing to try to save their colleague. They felt so helpless.  The surgeon had been complaining of upper back pain while hiking yesterday and most people on the team feel he likely had a cardiovascular event as the cause of death.

Now there is a legal turmoil going on between Egypt, where he is from and Ghana.  There are strict rules to follow and questions to be answered when a foreigner dies in another country. These are in place to decrease the likelihood that Egypt, (or other countries,) will sue Ghana in the future for “bad acts” around his death.  One of our Project Coordinators has left for Accra to deal with officials from the two countries’ embassies, the police and officials to be sure that the required paperwork has been completed.  The family just wants his body home.  What a sad mess.  After a long discussion among themselves, the surgeons and anesthesiologists decided to go ahead with the day’s schedule feeling that the surgeon would not have wanted the patients to be sent home without surgery.  We ended up starting late again, and in the end, six patients were moved onto Wednesday’s schedule. There were about an equal number of babies with primary lip closures and older toddlers and children with palate repairs.  On the local table, the steady stream of adults with first time lip repairs or revisions of previous scars continued.  The only aggravation related to surgery was the cancellation of one of Ella’s long-time patients. This little girl has a mild form of ectodermal dysplasia. It causes dry, peeling, thickened skin that is tight around the joints.  Hair can be sparse and teeth and nails are also affected.  She’s six months old and was to have her cleft lip closed.  Ella has followed this child since her premature (27 weeks) birth and long NICU stay, and has remained friends with the mother.  The child is bright and has just a unilateral narrow cleft lip.  She fasted most of the day and then the Pediatric Intensivist (PI) convinced the surgeon that with her condition, she wouldn’t heal well.  Luckily, Ella was right there and fought for her patient.  They compromised on getting labs to show she absorbs her food and has no liver problems.  If the labs are normal, they will “consider her” for Wednesday.  More on the PI in my general comments below.

 Ella will stay late tonight and Hans will take tomorrow.  While he claims to feel comfortable, I’m a bit nervous because it’s his first mission.  He’s obviously medically qualified; his career was spent in Pediatric Oncology and Pediatric Intensive Care medicine.  He was and still is a wonderful teacher of the medical students and residents. Finally, he is a substitute teacher of Spanish and French at the high school in Stockholm. This is a new style of medicine for him, but he is experienced in the care of very sick patients.  He can call me back if he needs to, and there is also an on call list that has a surgeon, anesthesiologist or the PI on each night if there is a sudden medical emergency.   It’s very important to Hans to take his turn in this rotation, to pull his weight, and the night nurses on the team are comfortable having him there.

At 9:30, Hans and I left with the day nurses and other staff from the OR and other areas who were done for the day. Arriving back at the hotel by 9:30 was such a luxury.  I stopped at the restaurant on my way to my room to get some hot water to make noodles.  The restaurant manager said, “Sure, Ma’am, I can give you water, but why don’t you use your kettle?”  “What kettle,” I asked.  “The one in your room, of course, on the desk, by the wardrobe.  You can’t miss it.”  “All the rooms have kettles,” was his parting shot, called out to me over the heads of the non-Op Smile restaurant patrons as I slunk away to my room.  Indeed, my room HAD NO KETTLE, though in searching for it I found 4 huge dead cockroaches under the bed.  I went up to the reception desk and asked authoritatively for “my kettle.”  When this drew blank stares, I said that the “RESTAURANT CHIEF” told me every room had a kettle and that I should use mine to boil water.  I then put on my most serious face, stood up tall like my Mama taught me, put my hands on my hips and said, “MY room has no kettle.”  “Oh, said one of the men, you mean you’re supposed to have a kettle?  We’ll bring you one.”  Playing the role of demanding, wronged guest worked, and half an hour later, the kettle magically appeared.  Tea, coffee, soup and instant oatmeal will follow.  My future is blessed.

Here are some observations on Ghana:  The child-rearing style here is a mix of warm indulgence and what Ella refers to as “whacking.”  I’ve seen plenty of both this week.  The mothers carry the babies and kids up to about age 6 years on their backs, wrapping lengths of colorful cloth around them and under their fannies, tying and tucking the ends in front. Unlike in Guatemala where the women cross the cloth over the chest and shoulders, the Ghanaian women wrap it around their chests and low backs.  The result is that the baby rides much lower on the back, often bouncing along on substantial buttocks, and the heads loll back in a way that’s a bit alarming to a western pediatrician’s eye.  The legs are spread wide to accommodate the mother’s girth, and it makes me suspect there is a low incidence of dysplastic hips in Ghana – they ride in their own splints.

Some of the young patients, ages 3-5 years have been openly angry when they emerge from anesthesia.  I think most little kids this age would be angry in this situation.  Mom is supposed to be their protector, after all, and she allowed the big bad doctors to take the patient and return her with a painful mouth.  Several kids have spent 5-10 minutes yelling at, their mothers, hitting and trying to kick their mother once they are fully awake on the post-op ward.  The mothers seem to understand, and rather than stopping the child, punishing him or her or trying to cuddle or jolly the child out of it, they either sing softly or say soothing things or pick a small stuffed animal from our stash and put it on the floor by the raging child.  None of them interfered with the child, choosing instead to sit on their mattress and wait until the child was finished. Eventually, the child would wear out and come to the mother who would accept a hug and gently soothe the child.  They don’t seem to talk about the event and they don’t cuddle or kiss them excessively.  They seem to accept that the child needed to be heard, and then they move on.

The babies return from the PACU with elbow splints made of tongue depressors held together with tape.  We have cloth arm splints with tongue depressors in little slots inside and ribbon ties here on the ward. They’re put on babies who can’t keep their fingers or thumbs out of their mouths after lip or palate surgery.  Kids who were thumb or finger suckers before surgery must learn to do without so they don’t disrupt the lip or palate repair.   By the second day after surgery, most are ready to have the splints removed. When I approach with my bandage scissors, they are scared and often crying, but when they realize that I’m not hurting them and their first arm emerges, free of the splint, they look wonderfully amazed.  Most move their arm around, bending the elbow and smiling hugely.  A few immediately shove their thumb back into their mouths, but most don’t.

Toilet training begins at about 4 months with the mother taking the baby off her back, standing him on the ground and making a shhhing noise or saying deedeedeedee.  The latter is for poop which the babies do on the walkway, in the garden, beside the shrubbery.  Great praise follows successful outdoor toileting, but woe be to the baby who pees or poops while wrapped on the Mama’s back. The babies don’t wear diapers, and the mothers carry a cloth, reaching back to wipe any drips until the baby is old enough to start toilet training.  I saw a mother on one of the hospital walkways stop abruptly and unwrap a baby girl who looked to be about 4 months old.  She sat the bare bottom baby down none to gently in the middle of the walkway, and while people flowed around them, began to loudly berate the baby for going pee pee and deedee while in the wrap.  She stood over the baby, waving the colorful wrap, now wet and soiled, holding it close to the baby so she could see the evidence of her transgression.  The baby stared at her for the first 10 seconds of the rant, and then burst into tears.  The mother let her cry, continuing to show her the wrap and point to the ground as the proper place for “deedee.”  Eventually she wound down and wrapped the baby up on her back again.  I guess the technique works.  Tiny babies, not yet walking, are dry and perform their “dee dee” as needed when unwrapped and prompted.  Since the mothers carry the babies well into their toddler years, it makes sense that they would want them peeing and pooping in the grass as soon as possible, rather than on Mama’s clothes.  The contrast with western “toilet teaching” was startling.
Almost all the babies breast feed here and they seem to have a closer relationship to the mother’s breast than I’ve seen in the US.  While the mothers are sitting around on the ground or floor visiting, their babies are nursing, pausing periodically to admire, pat, knead and hug the breast before resuming their meal.  It gives the appearance that the breast belongs more to the baby, rather than just being a food source.  We went over to see the neonatal intensive care unit, and there was a breast- feeding group going on.  Babies who do not have respiratory issues are started at the breast at about four hours of age.  Otherwise, the mothers sit in the nursing group and express milk for their preemies to receive by tube.

Every morning, a large group of adults and kids down to about age 6 or 7 run by on the roadway in front of the hotel.  Some run backwards and some stop periodically to do pushups, pullups and a variation on jumping jacks.  The local volunteers explained that this is “Keep Fit,” a program that goes on all over Ghana.  Adults and youth form clubs and have training, competitions and tournaments to promote health and fitness.  Education is also strongly emphasized in Ghana, even in the rural areas. I don’t know the literacy statistics, but all our Ghanaian volunteers agreed that children everywhere in Ghana have access to good schools. The children and adults here have beautiful teeth.  I haven’t seen anyone eating candy or drinking soda, and the kids don’t like the dilute juice we routinely use for hydration. It’s too sweet.  They want water.  When we ask the mothers if anyone smokes around their baby, a routine question on the screening form, they seem universally appalled.  Who would do such a thing?  I haven’t seen even one person smoking since I’ve been here.  I thought I saw a young mother with a cigarette in her mouth yesterday, but it was a piece of wood used to eat with in place of utensils.

The hospital is strictly segregated by gender with men’s and women’s wards for each specialty.  Our patients caused a dilemma for the Matron in charge of our ward as the rule is that no adult men can spend the night on a ward where women are present, either as patients or attendants to patients. We, of course had both adult male and adult female patients and lots of mothers around.  If we were to insist on having our male post-op patients stay on the ward for the night following their surgery the night, routine protocol for all our patients, the rules would explode.  Despite our unique situation, the Matron remained immoveable on the idea of men sleeping on the ward. Luckily most of the adults had their surgery under local anesthesia, and therefore didn’t have to be observed while they woke up.  In the end, we sent them back to the shelter in the late afternoon, thus avoiding a mixed gender ward after nightfall.  We did have an occasional child who arrived with his or her father instead of mother.  In those cases, we just didn’t tell the Matron and fortune smiled upon us  ; she didn’t find out.

On this mission, someone decided that it would be fun to have “theme days.” Practically, this means the team members wear shirts or accessories related to the day’s theme, and Child Life gives the kids theme related toys.  Yesterday was Superhero day, followed by Disguise day, Tropical Day and finally, Sports day.  I went to Goodwill before the mission and bought a Superman T-shirt and a youth football shirt to wear on the appropriate days.  As I was walking from the post-op ward to the OR to get more oral rehydration packets yesterday, proudly displaying the Superman emblem on Superhero Day, a small boy, about seven years old, a sibling of one of our patients, stepped directly into my path and flashed me a huge smile.  “Madam, may I have your shirt?” says he.  “It’s the only shirt I have,” I answered, a bit taken aback.  His face immediately transformed from that of ‘the most wonderful smiling boy to whom you would, of course, LOVE to give the shirt off your back,’ into ‘the devastated, heart-broken boy who will surely die without your shirt.’ He put his hand over his heart, slumped his shoulders, let his knees sag and said, in a tiny voice, “But I love Superman.”  At first I repeated that it was the only shirt I had and said something about wouldn’t it be silly if I gave him my shirt and had to run around in just my underwear shirt all day.  When he just looked sadder – a career on the stage is surely in his future – I detoured to the OR locker room and got a scrub top to wear and handed over Superman.  Though the shirt was way too big and very sweaty, the boy was ecstatic.   I’m not sure he’ll ever take it off.