Visit to Lemur Preserve-Madagascar 2016

After arriving at the hotel, we had a quick lunch and then loaded up the busses for a “short” 10 mile drive to a lemur preserve.  The Saturday afternoon traffic in town turned the drive into a hot 1 ½ hour trek, this directly after the four hour, “are we going to hit that truck head-on, go over that cliff, crash into that Zebu-driven cart full of chickens, crush that family walking along the road,” journey from Antsirabe.  It turned out to be more than worth the aggravation of the bus trip.

So, why have a lemur preserve?  Lemurs are endangered in Madagascar and therefore world-wide.  Because of deforestation, they have lost most of their habitat.  Predators include snakes and the Fusa, a type of giant mongoose.  Although it is illegal, “forest people” still eat them as there is no other readily available source of meat for them.  Despite preservation programs, the number of lemurs in Madagascar is still dropping.

There are a variety of Lemur preserves in the country, some more like zoos and some that cater to tourists who want to hand-feed, touch and hold the lemurs.  This preserve tries to provide a somewhat more natural environment, though of course it is not the same as the wild.  People are not permitted to touch the lemurs nor the native plants which are also cultivated and displayed.  There are no fences to keep the lemurs in the preserve, but they tend to go out only briefly and then return.  The guide explained that on one side there is a river, and lemurs hate to get wet.  The second reason is that there are no predators in the preserve, and there are no people there who are eating them. The park personnel put out food four times a day, leaves, fruit and vegetables.  They also give the lemurs honey on holidays and “birthdays.” Apparently lemurs love honey.  Lemurs also eat bats when they can catch them.  Finally, almost all species of lemurs are monogamous and form tight family groups.  This social connection keeps them in the preserve.

Before we saw the lemurs we saw a few of the other attractions at the preserve.  The first was a huge 16-17 year old grass and mud nest made by Hamerkop birds.  These are very large, fish-eating birds, about 22 inches long whose heads, when viewed from the side, look like a hammer-head.  They add to the nest each year and currently 5-7 birds share the nest.  They enter through a round hole that leads to a tunnel in the side of the nest.

Next we saw some varieties of Baobab trees.  There are 7 species in the preserve, 6 of which are indigenous to Madagascar.  The ones in the park are 15 years old and quite small, but typically they live to be 500 years old.  The oldest known Baobab tree in Madagascar is in the south of the country and is 1000 years old. The age is determined by counting rings.  There are also dwarf Baobabs.  All of these are on Shutterfly which I will eventually organize and label.

We saw a Napoleon’s Hat plant, named for its shape. After a rainstorm, it’s full of water and birds drink from it.  Tortoises love to eat it.  Traveler’s Palms are large trees that grow all over Madagascar.  A traveler can cut into the base of the trunk and water will flow. The leaves can be used to keep you dry in a rainstorm and to wrap food.

Now, on to the lemurs.  There are nine species in the park out of 33 species indigenous to Madagascar.  Some lemur facts:  all lemurs are endangered, they never hang by their tails, they have no claws but have thick ridged paws for clinging, they have opposable thumbs and big toes for grabbing, they don’t use tools, they eat leaves, never drink, and as a generalization, live 20-25 years.  They are mostly monogamous and in most species, the newborn rides on the mother’s abdomen for the first three weeks and then moves to her back for the next 7-8 months.  An exception is the Black and White Rough Lemur which I will discuss below.

First we saw the Dancing Lemurs, named because of the way they move. They dance around on the ground and through the trees on their hind legs, leaping great distances. A single baby is born after a 5 ½ month gestation.  Next were the Black and White Rough lemurs.  They move on all fours and live in an area of Madagascar where there are more predators.  They generally have 2-4 babies after a 90-day gestation to ensure survival of the species. Instead of carrying the newborns on her abdomen, the mother makes a hanging nest for them high in a tree where they stay for the first three weeks before moving to her back.

The Coqurelsifaka is another specie of dancing lemur.  They have white bodies and black limbs.  They also move mainly on their hind limbs.  The Ring-Tail lemur has a striped tail that always has 14 black rings and 14 white.  They move on all fours like the Rough lemurs.  Finally, we went into a dark building to see the nocturnal Mouse lemurs, the smallest of the species.  They are indeed tiny, with the huge eyes of nocturnal animals.  You will find way too many photos of the lemurs on Shutterfly. There are also photos across the riverof a "typical village."  The river is red and muddy from the soil that washes into it from deforestation but is not polluted, according to the guide.
At the end of our preserve tour we saw an Umbrella tree, named for it’s shape.  We also saw some tortoises with remarkable patterns on their shells. The ones in the park are 70 and 72 years old.

The trip back from the park took only 30 minutes since traffic in the city had diminished.  A large group went to a restaurant and the rest of us had a quiet supper at the hotel restaurant. Karen, one of the recovery room nurses wanted to look at a bracelet in the jewelry shop and couldn’t decide whether to buy it.  She told the proprietress that she had to think about it and would come back tomorrow, (Sunday.) The woman told her the shop would be closed.  “Why will you be closed?” asked Karen. The woman stared at her rather severely and then put her hands together as though praying. Karen, who in her defense was as exhausted and disoriented as we all are, still didn’t get it. “You mean you aren’t open in the morning?” The woman lifted her touching palms a little higher to be sure Karen could see them, and I nudged Karen and whispered, “It’s Sunday tomorrow.”  Of course then Karen was mortified and tried to explain that she didn’t know what day it was and apologized.  We made a quick exit, definitely feeling like ugly American pagans.  On these missions, I feel totally disconnected from “the world.” I never watch the news or hear about world events, and only know the days of the week as they relate to the mission schedule – screening day one and two, team day, surgery days 1, 2, 3, etc.  It’s a different reality.

Today is Sunday and we leave for the airport in about an hour.  My bag weighs 43 pounds!! All those toys I brought made up the extra seven pounds I came with.  Thank you for your interest in these missions, and as usual, please let me know if you would like me to remove your name from my blog list.  I will definitely NOT be offended.

Last Day Madagascar 2016 - and a few notes

We are back at the hotel in Antananarivo, the capital of Madagascar.  Most of the team leaves tonight on a flight to Paris and then on to their various destinations.  Three of us leave tomorrow at 3:00pm for Johannesburg and then JFK where we split up.  I’ll arrive at Logan late morning.  This has been an exhausting mission but extremely satisfying in that we were able to do surgery on 166 patients. Because Headquarters Op Smile in Virginia made the decision to let the the “floater” surgeon do cases under local anesthetic each day while being available to break scrub to help with any emergency, we were able to do primary lip repairs on seven patients age 14 years and up each day.  This translated into 35 young adults who can now step out into the world, confident that no one will be targeting them.  One group of three teenage boys came from nearby villages and had bonded over their difficult child and adolescent years.  As they were leaving yesterday, some clueless person asked if they thought the girls would notice them more now.  As I was trying to curtail my anger over the insensitivity of the question, the boys began to tease one of their group about a particular girl he was interested in and joked about how this boy had been working on his muscles for years. With his new handsome face, They were sure she wouldn’t be able to resist him.  They left in a great mood and I had to do one of those attitude adjustments on myself that seem to occur so commonly on these missions.

Another “opportunity to open my mind to different ways of doing things,” came yesterday.  An 11 month old 8 pound baby came back from the shelter on Wednesday to be checked because his lip, which had been closed on Tuesday had split open at one spot right in the center of the suture line.  He had subcutaneous sutures (dissolvable  stiches under the skin,) and Dermabond, a skin glue on the outside.  (Unless the suture line is cleaned gently, the Dermabond can dissolve and the superficial layer of the skin can pop open.)  In his case, though the open area was small, it wouldn’t stop bleeding.  The surgeon came to look at it and placed a piece of gauze over it with tape holding it tightly to create a pressure bandage, but the bleeding continued.  After several “mustache bandages,” the surgeon placed Steri-strips and another pressure dressing over the suture line and sent the patient back to the shelter. In the afternoon the parents returned with the baby because the dressing, though still in place, was soaked through and blood was dripping from the lower edge. The surgeon took it off and reapplied the Seri-strips, put on a new dressing and told the parents to return Thursday morning, keeping the baby NPO after four in the morning in case he had to take the baby back to the operating room. On their return Thursday morning, the bleeding had stopped, but there was a large dry hematoma stuck to the incision line.  The surgeon reassured the parents and instructed me and the nurse to apply wet gauze to the hematoma, changing it every 15 minutes.  I was positive that when the clot began to dissolve, the incision would begin bleeding again and felt this would be a waste of time.  Both the nurse and I were already running our buns off and didn't really have time to keep track of every 15 minute dressing changes. I also was sure that even if it wasn’t bleeding, there would be a big hole underneath the clot and a very unsatisfactory scar. Between us, the nurse and I changed the dressing every 15 minutes for four and a half hours without seeing any change in the hematoma.  However, at the five hour mark, the surgeon came to check the progress.  When he removed the gauze, ¾ of the hematoma came with it, revealing beautiful smooth pink skin underneath.  The parents were ecstatic, the surgeon had a big grin on his face, and I was dumbfounded.  He stopped the soaks,  gave the parents a tube of ointment to apply three times a day and sent them back to the shelter.  His method avoided a second trip to the OR and likely there will be a perfect result.  Live and learn.

A few little notes: Parents on the wards get meals delivered by Op Smile.  They come in plastic boxes and contain rice (a staple here) with vegetables and spices mixed in and meat or chicken or eggs.  I posted a picture of one of the boxes. Post-op kids who are not on clear liquids get a local home-made yogurt that is full-fat and delicious.  There are a moderate number of cockroaches in the hospital.  Nobody seems surprised or excited.  I’ve been eating the vegetarian meals that we get since the others have Zebu or undercooked chicken.  Our lunches come in Styrofoam boxes that contain either rice with veggies and a hard boiled egg, chicken or Zebu, or sandwiches on a roll with ham, beef, chicken or, for the vegetarians, shredded cheese and mayonnaise.  They remind me of what was served to the few vegetarians that were in my dorm at Stanford in the late sixties.

Madagascar is a very poor country.  On our drive to the hospital each morning we see people and dogs digging in trash piles along the road, competing for the best stuff.  Wherever we go children and adults are trying to sell trinkets and other hand made items.  They push them into the bus through the windows and drop them, hoping we’ll be too embarrassed to drop them back out.  The population of Madagascar is 22,000,000, up from 20,000,000 in 2004.  This explains all the brickmaking and construction along the route to Antsirabe.

The last blog entry was rather short, so as a brief follow up, the girl who bled had a fairly rough time in the OR as the artery that had cut loose was very difficult to isolate.  However, it was eventually found and cauterized and a catheter was put into each nostril, the balloon blown up and then the catheter pulled tight to put pressure on the adenoids.  She was kept in the recovery room all night; Isabel, the intensivist “slept” in the bed next to her and the mother slept in the next bed.  Isabel was amazing in that she engaged the mother as her “assistant” in the care of the child.  She explained that she was going to keep the daughter sedated all night so that she wouldn’t be uncomfortable from the tubes, but if the child did wake or become upset, it would be the mother’s job to get into bed with her and soothe her so that she wouldn’t dislodge the tube or her IV.  The mother went from being very frightened to taking on her role very seriously.  In the morning when the surgeon, anesthesiologist and Isabel very slowly first deflated and then removed the tubes, they did it with the child seated in the mother’s lap in the bed.  The mother played an active role in calming the child and all went smoothly.  There’s been no more bleeding and the child is spending an extra few days on the pediatric ward under the care of the local ENT surgeon who came in to help when she was bleeding.

Yesterday was our “1/2 day” of surgery and we did 23 lips, all under local anesthetic. We also admitted a one year old, two days out from his surgery, with cellulitis of his lip. He had IV antibiotics and stayed until this morning when he changed over to oral meds. One of the babies was cancelled because of fever, cough, wheezing and vomiting and needed IV fluids, so he needed to stay. So after all the surgical patients went home and we packed up our stuff, we still had two patients who had to spend the night.  Two of the night nurses came in, therefore missing the team party.  Luckily they are Op Smile veterans and didn’t really care.  By the time the last five of us – team leaders, clinical coordinator, etc. got to the hotel, the party was in full swing with local vendors, local dancers and a local band in the courtyard parking lot.  I managed to dress up and stay for part of dinner, but I still needed to pack and have my bags downstairs by 6:00 this morning.  One of the surgeons and I had to return to the hospital to discharge the two babies as the bus was leaving for the capital at 7:30.

Though the dinner was so-so, Charlotte, the local coordinator had arranged for the mother of an 8 year old girl who had received her third operation on this mission,  to speak to the team about what Op Smile means to parents.  The mother’s English was slow and sometimes hard to understand, and she started at the very beginning, telling how she and her husband had three boys and had decided that their family was complete but despite her IUD found she was pregnant.  When their daughter was born with a cleft lip, they were devastated but luckily a friend knew about Operation Smile and the child has received timely care.  The talk was getting long and people were tired and hungry, and there started to be a little shifting and muttering in the back of the room.  The mother then began to speak about the people who were not chosen for this mission and said that she had been in that position two years ago and explained how heart-broken and angry she was.  She said that she knows the parents sometimes say “bad, angry things” about Operation Smile when they are not chosen, be cause they have travelled so far with the dream of a changed life for their child and themselves and then have to return home to the same sad life and the same situation of being “other.”  She asked us to forgive them because she knows from having been through it that these parents don’t  mean those things, they just want their child to have what other people have, to not be stared at or treated like a lesser person.  She said that when they go to other doctor appointments, they’re made to wait till the other patients are gone and are treated “like dogs.”  “Here, you treat us with respect and it’s new for us.  We almost don’t know what to do when you look right at us and our child and talk to us like we are the same as you and like we deserve to be treated kindly, and it’s a strange feeling for us.”  The room was silent and then applause erupted and everyone stood.  She looked bewildered, and when things quieted down she said she didn’t understand why we were applauding her, we should be applauding ourselves; she was just bringing the message from the grateful parents.  Charlotte explained we were applauding her strength as a mother and advocate for her child and her courage to stand up in front of this group. I don’t think there was a dry eye in the place. There certainly was no more muttering.

I did go up to pack then, but the party went on until three.  This morning, after discharging the little guys and checking on the girl with the bleeding who was eating yogurt, we came back and drove for 3 ½  hours to this hotel.  The road is extremely curvy, and once again the driver seemed offended by all in front of him, passing on curves, blind spots – no challenge too great.  We made it by about noon, had a quick lunch and left for a Lemur preserve.  Since this blog entry is way too long, I’ll start another about the lemurs after I do some suitcase rearranging – or maybe tomorrow.

A Blur of Days- Madagascar 2016

It’s 11:00 pm Thursday Madagascar time and I’ve been back from the hospital for about half and hour.  Isabel, the intensivist and I went over about 6:00 this morning to see the pre-ops, so it’s been a very long day. It’s also been eventful, but I’ll get to that. I’ve been scribbling down notes to myself of things I want to include in my blog, so I’m going to try to get these disjointed observations down before I tell about the day.

The first thing is names. Madagascar names are impossibly long and for someone from the US, unpronounceable.  A few examples from my patient list are Haritinatolojanahary, Fahendrena, Tolotriniavo and Voahiranah Judicael. The peoples’ appearance reflects their multinational heritage. They have a blend of Asian, African and Indian features.  There was a two year old on the ward post-op for lip repair. I was trying to find out what he usually ate so we could bring him something other than juice.  His parents list included meat, cassava, vegetables and rice.   We had none of those, so he happily ate yogurt.  Parents here, both fathers and mothers, are very nurturing.  They wrap their children onto themselves with lengths of woolen cloth, tucking it under to make sort of a seat for the child.  As a group, they are calm and soothing and help their children cope post-op.  Almost all of the mothers breast feed, so the babies with lip repair can go right back to the breast.  Again today we had several young men and women who had primary lip closures.  They had great repairs and except for the post operative swelling, their lips look near normal.  They certainly will be able to walk down the street without attracting unwanted attention.  The young men in particular couldn’t stop looking in the mirrors.

Yesterday the water in the whole hospital dried up mid-afternoon.  No one could figure out why. Surgery had to go on, so two five gallon jugs were found for scrubbing and instrument washing.  Today the water’s inexplicably back on.

Young children in Madagascar think white people especially those with blond, red or white hair, are ghosts who might drag them off to the spirit world.

I’m trying to post some photos of the pre-op area with kids playing with play-doh, coloring, and today being entertained by the young Mormon elders with pipe cleaners.  I may have to try again tomorrow.  So on to today. We did 39 surgeries today and have 23 scheduled for our “½ day" tomorrow. We’re on track to complete 165 operations this week.  It’s been incredibly busy but also very gratifying, especially with the young men and women.  It’s also been very frustrating having to turn away so many.  There is another mission here in April, and I hope they restrict it to the people who were left out today.

Today moved smoothly until mid-afternoon and then fell apart completely.  First an eight year old came to the ward from the recovery room, and as she came out of her remaining anesthesia, she became completely hysterical.  It’s not an unusual reaction, especially with children, but we could not get this girl to stop. Finally, we had to send her back to recovery where the intensivist put her back under anesthesia and brought her back up slowly.  Next, a seven year old boy developed airway swelling after he had been on the ward for about 15 minutes.  He also had to go back to recovery and ended up with a nasal trumpet, a tube that goes into the nose and keeps it open.  He’s back on the ward but also sedated for the night. A baby developed wheezing and needed multiple nebulizer treatments, three other kids started vomiting and needed IV’s that they had previously pulled out re-inserted, and a five year old girl developed arterial bleeding from her adenoid and had to go back to the OR to get it to stop.

Tomorrow is a “half-day.”  We have just 23 patients – all lips. We then pack up and the plan is to get to the hotel for the final party around seven. Hmmm.
More later. Off to bed.

Madagascar 9/2016 - First two days of surgery

I hope you all have been able to access Shutterfly and see the pictures. I’ll try to post more tonight but it may be tomorrow.  At some point I’ll organize them, especially the pre and post op photos as best I can, but for now, you’ll have to guess which photos go together as I’ve had no free time.  I didn’t try to do a blog entry yesterday because by the time I got back to the hotel it was 10:30 and I was just too tired.  Isabel, the Pediatric Intensivist and I left the hotel Monday at 6:15 after “breakfast,” so that we could see the first two rows of patients and have them ready for the OR before the surgeons arrived at the hospital.  Breakfast at the hotel is the same every morning.  There are baguettes but they are mainly air rather than the dense and chewy bread I expected when I saw them.  There are also six or seven pastries, all with different shapes but made from the same dough – chewy and full of chocolate chunks.  Finally, there is a traditional Madagascar soup.  The soup has a thin broth, white rice, some sort of green leafy vegetable, a bowl of Zebu meatballs and another of an orange powdered spice to be added or not at the preference of the diner.  I did taste the soup, though not the meatballs or spice.  It wasn’t actually my cup of tea.  What I do love is the pitcher of steamed milk they have for the coffee.  It is held tightly in the possession of the “coffee matron,” who serves both the coffee and the milk.  I’d discovered it our first morning at the hotel and my breakfast had consisted of coffee with steamed milk and some baguette.  On Monday, when I asked for coffee with milk, the guardian of the pitcher shook her head and tilted it toward a large bowl of what appeared to be custard in front of the coffee cups.  When I asked her what it was, she looked right at me and said, “steamed milk, Madame.”  I held her stare for a moment – just to let her know I wasn’t naïve enough to believe her preposterous story, and took my bitter black coffee to the table with my baguette.  Today, the milk was back.

This blog entry will likely be a bit choppy as I have a list of “interesting tidbits” to impart.  But I’ll get to those after a description of the first two surgical days.  Unlike other hospitals I’ve been to for Op Smile, the pre-op ward doesn’t actually house the pre-op patients in the traditional manner.  All the patients for this mission have been brought in from around Madagascar; one was even flown in by a sponsor.  They are staying at the shelter and that’s where all their things are.  The night before surgery, they come to the pre-op ward bringing only what they will need for overnight.  For some this includes the clothes they are wearing and a blanket to wrap up in.  Others bring a sheet for the bed, formula, pajamas, etc.  The rooms on the pre-op ward have rubber mattresses on the floor, eight to a room, and a bathroom at the end of the hall.  Before Isabel and I arrive, the night nurses wake up the first 12 patients scheduled for surgery, row one and row two, do their vital signs and have them put on gowns.  They then sit on benches in the hall.  When we arrive, we check the patients to make sure they haven’t gotten sick, check the chart to be sure the consent is signed, the “code sheet” that lists all the drugs for a code with proper doses is there, make sure pre-op labs are present and sign pre-op orders.  By then, the surgeons have arrived, and I go downstairs to round with them. I pre-write the discharge sheets but still have to sign them once the surgeons have been by.  While I’m with the surgeons, Isabel is continuing to do pre-op checks on rows three and four before she goes down to the recovery room to get ready for her day.

 When I’m done with discharges, I go back up and pre-op rows 5-7.  The reason to do the pre-op checks on all the kids first thing is that if a patient is sick or doesn’t show up then the schedule needs to be rearranged.  It also means that a patient from the stand-bye list gets lucky.  Four standby patients had surgery today, and I have never seen such happy people.  There were two adults with lip clefts and two three year olds, also with cleft lips.

We have a local anesthesia table manned by a different surgeon each day.  All the patients are older teens or adults with cleft lips, and having their surgery under local anesthetic is the only way they could get on this mission.  It was so satisfying to do their pre-ops this morning; they were so excited to finally be having their dream realized. When they got to the ward, I gave them a mirror, and they couldn’t stop looking. It’s joyful but also so sad it came so late.  One 24 year old man has known about programs to fix cleft lips for several years, but none of them were free.  He heard about Op Smile and decided to come on the chance he would be chosen.  Two of the patients didn’t have clefts but rather facial deformities from Noma.  Their outcomes are not as good due to the massive tissue loss, but still they were pleased. It’s getting late so I’ll add more patient stories next time.  Here are a few “tidbits.”

The staff bathroom on the ward has no seat on the toilet and the sink doesn’t work.  The toilet leaks.  The choice is whether to not drink much and stay dehydrated so you don’t have to go in there or drink and take the plunge, so to speak.  I usually choose dehydration

In Madagascar you push light switches down to turn them on, up to turn them off.

Every day at lunch at the hospital they serve ketchup flavored potato chips.

There’s a machine in the break room that serves coffee, espresso, hot chocolate, hot water, coffee with milk and hot milk at the push of a button.

South African and Swedish anesthesiologists are fantastic at pain control.  They do infra-orbital and temporal blocks, use clonidine, fentanyl, nubain and propofol all together.  The wards are very quiet.

The patients smell like farms, hay, animals, rain, grass – reminds me of Guatemalan villages.

Both mothers and fathers keep their babies and children close and wrap babies through toddlers onto their bodies in long woolen lengths of cloth.  It's similar to the Guatemalan custom except the baby is in front.  I took a photo or two and will post them.

Rooms and beds are not cleaned between patients.  There is some occasional sweeping of floors, but that seems to be the only housekeeping.

Well, I’m nodding off so I’ll post this and try again tomorrow. We’ve done surgery on 72 patients so far.

Announcement Day Madagascar 2016

Today was selection day, and Charlotte, the young woman who is the Madagascar Op Smile coordinator developed a new way to tell the patients and parents.  The usual way is to have all the patients gather in the morning and then have one of the surgeons or the program director give a little speech about how we would have loved to do surgery on everyone but that for medical safety reasons and for reasons of age and surgical benefit, some patients would not be having surgery on this mission.  There would be other missions, the next one will by in… (April 2017 in this case…) and that Op Smile will contact those who did not make it onto the list for this mission.  After that, the names of those who are scheduled for surgery are read off, “in no particular order.”  When it is done this way, those who are chosen are very happy and often laughing and hugging family members.  Those who are not chosen, especially if they were expecting to have surgery, are disappointed and probably feel like they are surrounded by a party to which they were not invited.  They aren’t just sent home; Op Smile coordinators speak with them and set up a plan for each patient, but it still isn’t the best environment for hearing bad news.

Charlotte’s plan was different in several ways.  The first thing she did was have the shelter director bus the patients over in four groups rather than all at once.  That alone made it feel much more personal.  Next, she had tables set up outside at the hospital on two levels.  On the upper level courtyard were the main table where the line of patients started, five tables for surgeons and their interpreters, and one table each for dental, speech and the feeding program.  On the lower level courtyard, down a set of stairs, a table was set up for each day of surgery, Monday through Friday with an Op Smile nurse and an interpreter.  At the main table, patients would step forward and give their number to Charlotte who would consult the master list. She would then send the patient with an Op Smile runner to the appropriate table.  If the patient was not having surgery, they went to a surgeon’s table and the surgeon, who had been instructed to take as long as he or she needed, would explain why there would be no surgery  and would answer any questions.  Each patient was also given a paper with the contact information for the April mission.

Patients sent to the feeding program table were mainly babies who were malnourished or under weight for age.  They will remain in the shelter for the week receiving help with feeding and return for the April mission as well.  The dentists, who are from Italy and Egypt, saw patients who need work under anesthesia which they will do in the dental unit in hospital here. They also will make obturators to fill the space of the open palates for those patients who are not having surgery this mission.  The obturators are like thick retainers and help prevent liquids and air from flowing up through the nose.  Finally, the speech therapists will see some patients who will stay this week for intensive speech therapy.

There’s a last group of patients that are very difficult for all of us.  They have conditions that are beyond an operation smile mission and likely beyond the expertise of plastic surgeons in their home country.  What they need is a miracle – some charity group or organization or philanthropist to take them on and treat them.  One is the 16 year old girl I saw with the extensive nevus, progressive left arm weakness and badly healed femur fracture.  She needs a combination of neurology, plastic surgery and orthopedics to make her whole.  Another is a middle aged woman who had noma, a severe infection that can occur around the mouth in malnourished people. It often results in gangrene and the loss of large amounts of tissue.  This patient lost most of her upper lip and jaw and the base of her nose.  She will need extensive plastic and maxillofacial surgery to reconstruct her face. The last on this mission is a young woman with a large benign facial tumor.   All of these people would be taken care of if they had access to modern health care.  What they need are guardian angels.

After lunch at the hotel, we went on a different type of team day.  Usually there is a trip to a beach or some other team building event. Instead, we went to two artisan workshops and a small shop of hand-embroidered linens.  The first workshop is run by two brothers who make utensils, jewelry, boxes and other things out of the horns of the Zebu, the Madagascar cattle.  The Zebu are raised by most of the rural people here and provide milk and meat, hides for warmth and dung to burn.  Nothing goes to waste, and these brothers have made a business out of the horns.  After the animal has been slaughtered, they remove the horns and heat them in hot water.  This separates the inner bone from the outer horn. Next they tap the horn with a wooden hammer and the bone comes out in one piece.  The bone is ground up into a powder and used as a medicine for headache and sinus congestion.  The brother giving the presentation said you inhale it and it feels just like ammonia. “Great for clearing up your headache.”  The horn is cut with a rotating cutting wheel they make from tin cans.  A washing machine motor runs the spinning wheel.  They use a hand made wooden mold to shape spoons and shell shaped necklaces.  They showed us the process of smoothing and polishing the horn using sand, denim cut from pants, clay and plants. They pour oil over the wheel while polishing the horn.  Black Zebu have black horns, white grow white, and the “marbled” Zebu have beautiful marbled horns.  They have a small shop with an amazing variety of objects made from the horns.

Next we went to a shop where a man makes miniature bicycles, rickshaws, cars and busses from found and recycled materials.  He uses rubber and wire from tires, fishing line, used IV tubing and small pieces of wood.  I’ve posted photos of both the horn and bicycle workshops on shutterfly that I hope will show up this evening.

Well I’m off to team meeting and tomorrow we start the surgical week. No more lazy days.

Screening Day Two Madagascar 9/17/2016

Today was the second day of screening, and we saw 156 patients, bringing the total to 356.  We didn’t reach the predicted 400 which is very fortunate.  It would only have meant more patients we would have had to disappoint at tomorrow’s announcement of the surgical schedule for Monday through Friday. I just returned to my room after the four-hour scheduling meeting, and though it was very sad to realize how many patients and parents will be disappointed tomorrow, it was also gratifying to see how thoughtful the scheduling team was in making their choices. There are various priorities for deciding who will be scheduled. I won’t go over them here except to say that they go from Priority 1 through Priority 5 with a few sub-groups thrown in, and we were able to schedule only about half of the Priority 1 and 2 patients.  Priorities 3 through 5 never made it to consideration.  This is the first time I’ve been on a mission where patients who fully qualified for surgery had to be turned away.  Other team members said they had experienced this on other African missions and in the Philippines where there is still such a need.  In the end, we gave precedence to the older kids and adults over the very young babies with cleft lips.  I’m in the process of posting photos to Shutterfly, and if it works, I think you’ll see just how amazing it can be for a teen or adult to contemplate have a normal face.  One of the 15 year old boys I screened today was very shy, but on the way out, he leaned over and whispered to the interpreter, “tell her I just want a girlfriend.”  Somehow I managed to keep it together to continue to see patients, but here this boy is, at 15, and he had spent his whole life being ridiculed and shunned.  He is, of course, a normal boy on the inside, and his hopes for the outcome of this surgery are that he might finally have a girlfriend.  He is on the schedule, so he’ll be taking the first step toward his dream.
When we were scheduling patients, we looked at age, distance travelled – some drove or road the bus for five days to get here, and how many times the patient had been turned away on previous missions. One 12 year old will finally get his lip closed after missing the cut in 2010, 2012, 2014 and last year.  Two more missions have been added this winter and spring, so I hope some of these kids can get treated.
Here are some stories of kids I saw today.  There was a 12 year old boy who needs to have his palate closed. Usually above age 10 it’s not that helpful for speech, but his boy had come yearly since age seven and the team felt obligated to do the surgery.  However, over the past year, he has developed huge tonsils and sleep apnea.  The anesthesiologists were nervous about putting him to sleep without first sending him to an ENT surgeon to have his tonsils removed. The only hooker is that in Madagascar, they don’t use anesthesia for tonsillectomies! They just reach in with a big scooper and out they come.  Needless to say, the boy is reluctant.
Isabel, the Intensivist who is actually a pediatric anesthesiologist but is acting as the intensivist this trip, saw a little girl who looked perfectly normal but had an 02 saturation of 79-80. Her heart exam was normal but a chest Xray was classic for Tetralogy of Fallot. An echocardiogram was normal though the expertise in reading it was a bit shaky.  Anyway, we had her come back to recheck her 02 saturation again, hoping it had climbed so she could have her surgery.  It was still hovering in the high 70’s, and I was about to give up when I noticed a slight sheen to her nails.  I took her to the window to get a better look, and I could see that she had on pale gold polish.  When the interpreter asked her Mom, the girl said it was her “princess polish.”  We got one finger clean and her 02 saturation shot up to 99%. So, a CXR, ECHO and lots of worry later, she’s off to the OR. I still don’t know why her heart looks like a page out of a cardiology textbook, but I’ve decided I won’t spend any more time feeling stupid.
I also saw an 8yr old boy with a cleft palate who had severe rickets.  His legs were very bowed and he had thickened wrists and bossing of his forehead.  Of course he has had no evaluation, but I’ll see if there’s anything to be had.  Then there was a 14 year old girl with a raised black nevus covering the left side of her scalp, neck, part of her face, shoulder and left trunk.  She was there because she wanted it removed but also because of gradually worsening weakness of her left arm and leg.  At first I couldn’t put anything together, but then I examined her leg and found a large deformity at the hip and shortening of the limb.  It turns out that she was riding her bike two years ago and fell off and fractured her femur, likely right through the hip. Her family took her to the hospital, but she was refused care because they had no money.  She rested at home until it “healed.” Now she has a “weak leg and arm.”  Once again, I’m stunned that any medical person could turn away anyone with her injury. I don’t know if anything can be done for her at this point, but I’ll check out the various traveling charitable organizations.  As far as the nevus and it’s possible relation to her left arm weakness, I’ll have to read up. I don’t if these can invade the brachial plexus (nerve bundle supplying the arm,) or not.
Finally, I saw a four year old girl wearing a beautiful white dress.  She was sitting demurely with her mother, waiting her turn to be seen. She’s beautiful now and once her cleft lip is closed she’ll be stunning.  I don’t know if she’s on the schedule; I hope so.
Well, I’m off to check if the photos made it onto shutterfly. There should be some patient ones and some street scenes taken through the bus window.  Tomorrow, after we make the surgery schedule announcement and get the wards set up, We’re going to a craft market.

First day of screening - Madagascar 2016

I’m going to start with the end of my day since I feel I should explain the last of the photos I uploaded in case any of you have been checking those out. I’m fairly frustrated with Shutterfly – I probably won’t use them again but would like to get through the mission without changing if I can.  Every time I post new photos they go through a big to do, acting like it’s a new album, showing only one and then finally posting them all along with a bunch of ads.  Of course it’s entirely possible that I just don’t know what I’m doing as my really smart brother uses them successfully all the time.

Anyway, last night, the first night in Antsirabe, I was in a double room but was assured by the desk clerk that when I returned from the hospital today, I would have a single room, “really nice,” (French style air-kiss from his fingertips emphasizing what a great room this would be.)  He told me to leave my bags in the old room on the first floor – what we would call the second floor – and they would be magically transported by the hotel staff to my new room.  When we arrived back from a long first day of screening around 6:30, I went to the office and was given a key for my new room, this one on the 2nd (3rd) floor.  I trudged up the stairs with my backpack and giant bag of baby/kid toys and exam equipment only to have the hallway go pitch black half way to my room. I stumbled along, and after missing it twice, managed to find the right door by feeling the raised numbers.  It turns out there are timed switches at the start of each hallway that must be flipped on before you enter if you would like  to have your way lighted.  Who knew? (not me.)  My luggage, of course was not there, but just outside the door was a large red plastic bucket with a medium sized red plastic scoop inside.  I assumed it had been left by the cleaning person – HA! – and went down to the office to find my bags.  They were, of course, still in my previous room, so I hauled them up one at a time.  A few minutes later, the desk clerk knocked on the door to “tell me a few things about the room.”  It seems the water pressure is low on the second floor, so if the shower doesn’t work, I can fill the bucket with water from the sink and use the scoop to bathe myself.  “How often does this happen,” asked the very tired and a bit cranky hotel guest from her “really nice room?” “Well,” says the desk clerk, usually between 6:00 and 9:00 in the morning and 6:00 and 9:00 in the evenings are the worst times because EVERYONE WANTS TO SHOWER THEN!!!!!”  Finally, he needed to “show me about the toilet.” Apparently the same low water pressure “sometimes” keeps the toilet tank from refilling. If that happens, I just take off the lid and push down on the big blue pump a few times and, voilà.
On the bright side, though there are no hangers, no hooks, no drawers, I do have three outlets if I unplug the television and crawl under the bed.

So back to the photo of the bare-breasted woman. Its of a painting, about 16x24 inches on the wall at the foot of the bed.  Lying in bed, unless your eyes are closed, Miss Sensuosity dominates the view.
Before I go to the other photos and forget about roosters and dogs, I’ll include them now.  Our day started at 6:00 am with breakfast in the hotel restaurant, followed by team meeting at 6:30 and departure for the hospital at 7:00. I set my alarm for 5:00 because I had to have my bags packed for the big room switch.  At 4:30 I was awakened by the vigorous call and response of several roosters.  It took me right back to last year’s trip to Guatemala when I persuaded my friend and former medical school classmate, Mary Rappazzo to go with me.  The daily 4:30 wake up calls of the Guatemalan roosters probably contributed to her lack of interest in returning.  The other person who jumped right into this trip was Bette Palovchik, the founder of Shuarhands, the foundation that funds the Guatemala program.  Bette was never happy unless there was at least one dog wandering around in our exam rooms, and I’m happy to report that there were three small terrier mutts who strolled in and out all day.

So, back to the photos, and I’ll keep it brief.  We screened 200 patients today and the first new photo shows them lined up ready to start the process. There are then a couple of slides of Christian, the scruffy looking guy with the beard and glasses, who is actually the team leader for anesthesia.  He’s South African and was going through the chart for all the first time anesthesiologists and interpreters. The blond woman in the front is a Peace corps volunteer who is interpreting for us. Then there’s a photo of most of the anesthesia team celebrating something, followed by some hospital scenes.

Today was the first of two screening days.  We saw 200 patients and there are 200 more here to be screened tomorrow.  There is a Swedish film crew here filming a documentary for Operation Smile. A television journalist, Malou von Sivers is the “star” of the show and a big Op Smile supporter. Her teenage daughter is here as well. She was born with a cleft palate so Malou knows what these kids and parents are going through.  They chose two kids ahead of time to follow, went to their homes to get in depth coverage, etc.  One is a four year old boy who unfortunately arrived sick and has pneumonia.  Malou and the film crew were involved all the way along as Jonas, an anesthesiologist from Sweden and I screened and then evaluated this little guy, trying to find a way for him to have surgery. We finally got a chest Xray and that was the end of any thoughts about surgery. On the bright side, it’s good he came as the family lives in a very remote village and he might have become very ill before anyone realized he needed medical care.  Also, those of you who watch Swedish documentaries might see me on Swedish TV.

Among the patients we saw today were several teens with untreated cleft lips.  With so many babies at screening, the surgeons plan to set up a sixth table and try to do the teens under local anesthesia just so they have a chance to have the surgery.  Even though I know the logical reasons to do the babies first, I’m really pulling for the teens. It will change their lives.

I also saw a three year old with a mildly low oxygen saturation. It’s a little tricky hear because we are at 4900 feet elevation and many of the patients come from sea level.  Saturations of 94-95% are common.  This child, however had an 02 saturation of 78-80.  Although she had no murmur and no symptoms, we got a chest Xray and she had a classic boot-shaped heart, seen most commonly in tetralogy of Fallot.  She needs an echocardiogram to see what’s really going on, her chest Xray looked like it came out of a textbook.

I also saw a very sad case.  A thirteen year old girl was there with her two month old baby boy. The pregnancy was the result of a rape, and the girl was sent off to live in a convent with an order of nuns that helps to “save the souls of girls who have been defiled.”  The grandmother has taken over care of the baby who has a bilateral cleft lip.  I always do a fairly complete exam on the under one year olds as they may not be having any regular care.  This baby had a large inguinal hernia that will need to be repaired in a few months.

Finally, I saw a three year old girl whose mother brought here because she isn’t speaking. She also had a few other things, a mild left sided weakness and mild left club foot, but when I asked Mom if the girl could hear, she said yes, the child heard well and understood everything.  Of course the child didn’t respond at all when I had Mom call to her from behind, without the benefit of gestures or lip-reading.  I think this child is also delayed, but her deafness likely will turn out to be her biggest handicap here.

So just a few short things before I wrap up for tonight.  We have great interpreters. Two are young Peace Corp volunteers who’ve each been here for about 18 months and will be leaving in another six. They both are fluent in Malagasy and seem very culturally aware.  We also have a young Baptist pastor who started out in the church of a Baptist missionary from the US. When the missionary went home six years ago, this young man took over the congregation.  He’s here just to help.  Finally, we have three young Mormon elders.  They are very nice and do a great job.  They dress, as is their usual style, in dark pants, white shirts and ties.  The rest of us are in much more casual clothing, but they seem comfortable with who they are.

The last thing is that when we were driving from the capital to Antsirabe, in a huge line of busses and trucks, the busses would stop periodically and open their back doors.  Though the busses already looked packed, people rushed to climb on. As traffic started up, the busses started as well, and the stragglers ran after them being dragged in by friends until the back door guy finally closed up.  I wonder how many people get injured or die each year trying to hop on moving busses?
OK, that’s it. I’ll keep my fingers crossed for Shutterfly.