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.
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