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.
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