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.
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