I’m back on land and once again in a single room at the Weston Hotel in Santo Domingo. I’m in this room because the three receptionists took so long and were so disorganized about checking us back in that they ran out of doubles before they got to me. We were actually back on land by around 11:00 am, and since we couldn’t get into our rooms until 3:00, the plan was to go to the crafts market where people could eat lunch and see at least a small part of Santo Domingo before going to the hotel. Since the ship had been an alcohol-free zone, some of the team members were craving a cold beer, so on the way to the market, we stopped at a roadside bar that featured huge communal bottles of beer, iced (!) mugs and Salsa music. As we were re-boarding the bus, Perla got a call from the hotel saying that our rooms were ready. One might think a trip to the market would take precedence over a Weston hotel room, but there was no contest. Since they’d had their beer, everyone wanted to satisfy the next hedonistic need, a hot shower.
On the Comfort, perhaps not so aptly named, 1000 people share the bunk spaces previously described. It’s divided into male and female sides, and there are several compartments. Each large compartment has 150-200 bunks with six very narrow shower stalls to accommodate all. Space on the ship is always “conserved,” so things like shelves, cubbies and towel racks are not included. The water trickles out and is tepid at best, and one is constantly bumping up against the cold metal sides of the stall. Soap and shampoo bottles are either clutched in your hands or sliding around on the floor underfoot. At the end of our long days, the choice was to skip the shower and go to bed hot and sweaty, or wait in the shower line in the dark, (lights always off for the day sleepers,) and brave the less than satisfying washing experience.) Finally, there was the “shame” factor. Fresh water is precious on the ship and we had been told in our orientation that Navy people call normal showers “Hollywood Showers,” and we would face silent ridicule if we indulged. This made us all add ‘rushing’ to our shower routines, joining ‘fumbling, bumping, slipping and cursing.’
When we reached the hotel, the lobby was crammed with people. There were two wedding parties with various small children, along with several other couples and families. We lined up at the desk, but it soon became clear that the receptionists did not have our rooms assigned, nor were they ready. In retrospect, they should have made up some excuse and asked us to come back, but instead, they took our passports and told us to wait in the lobby for “a few minutes.” As you might imagine, minutes turned into hours, but they continued to give us cheerful updates about imminent room assignments, so no one wanted to leave and risk missing out. Every once in awhile a couple of names would be called and keys handed out, but it was a very slow process. When there were just four team members left, my patience ran out. I went to one of the receptionists and sweetly told him that I had be waiting for three and a half hours and that I needed a room now, please. Voilà! I’m in my single.
So, back to the day’s events. I awoke at 4:00 this morning so I could strip my bunk and pack up my bag before heading to the ward. The plan was to have the patients on the Tender at 9:00 and for us to be ready to go at 9:30 when it returned. Luckily, my new bunk is close to the door to the shower room, and there is a small light there. On the ward, some of the patients were awake so the nurses and I completed their discharge papers and I did a little bit of packing of medicines until the mess hall opened at 5:00. At breakfast, I met up with the day nurses and we all rushed through our last meal on the ship, returned to the ward and finished the discharges in time to attend the last muster. The adult patients were all very pleased with the outcomes of their surgeries. One young man, who is a professional BOXER!!! was upset because his surgeon told him not to box for 8 weeks. This guy had come in for a lip scar revision and now has a gorgeous smile – you can barely see that he ever had a cleft lip – and now he wants to go into the ring and let someone bash it to bits. Well, perhaps he’s a really good boxer and can protect his face.
When the patients had gone, we did our bed stripping routine, but were spared the cleaning of the ward. Thank goodness, the Navy will do their own thorough cleaning. The next hurdle was getting our bags from the bottom of the ship to the top deck to load them onto the Tender. There is an elevator, but ship regulations allow for ‘patients only’ on the elevator, so we had to carry or drag our bags up nine decks. Before we could load them, we had to load huge boxes of left over cargo from our mission. We formed a line to pass the boxes from one person to the next from the ship down a hallway to the Tender, but it was a sloppy line and strength and coordination varied from person to person. Boxes fell, came open, and new people arrives and jumps into the line, destroying what little rhythm had developed. Soon a crowd of Navy men had gathered, watching us, snickering and shaking their heads. The commander who was in charge of getting us off the boat was not smiling at all. He kept shouting instructions, pacing around and getting redder in the face each minute. There was a large wheeled cart nearby, but it was not designated for this purpose, so we “did our best” until the cargo was on board. As the last box was stowed, one of the sailors on the Tender shook his head and said, “You guys are definitely not Navy.”
The rest of this entry is being completed Sunday morning before I head for the airport – hence the past tense.
My original plan had been to take a shower and then go see the craft market, but by the time I got to my room, the plan had morphed into taking a shower and quick nap before the team dinner. Of course the hot water had long since been used up by those who’d been “en-roomed” before me, but since I had my single room and was hot and sweaty, I didn’t care. The team dinner is a traditional event held on the last night of each mission. We went to a very nice, traditional Dominican restaurant where we had delicious food and watched a couple performing traditional dances. One involved first the man and then the woman placing a bottle of rum on a mat on the floor and then balancing on the ball of one foot on the top. Next, the partner twists the other person back and forth to build up momentum until the person can spin rapidly. Though they both managed it easily, I had visions of the learning process with broken bottles, ankles, lacerations, lakes of blood…
This dinner was our only Dominican cultural exposure this trip and reminded me of what one misses out on by doing a mission on the Naval ships. When you’re on the ship, what you are immersed in is the culture of the Navy, fascinating in it’s own way. However, the culture of the patients was subsumed by the environment of the ship, and except for screening day in the park and team day on the beach, we were on the ship the whole mission. Both the park and the beach were contained, groomed spaces, not indicative of the “real” D.R. Usually missions are held in towns or cities where you get to see extended families and observe local culture. Working in the local hospitals is fascinating as well. The facilities on the Comfort are excellent and everything is clean – both big draws, but I think I’ll opt for the local hospital on my next trip, wherever that may be.
Jonathan, the surgical team leader was called to the Op Smile office here just before the team dinner to see a 10 month old whose cleft lip had been repaired on Monday. His father had called to say it was bleeding. When Jonathan arrived, he found that the lip repair was totally disrupted. It turns out, the baby had been crawling, had reached then end of the room and launched himself down two steps, landing on his face. Since repairing the lip would mean a return to the operating room, and we can’t return to the ship, Jonathan did local wound care, and the baby will have to wait six months until the next mission in Santo Domingo to have the full repair again. Everyone feels so bad for the parents who had been celebrating this major event.
Finally, Bruce, the intensivist will be going on a mission to Haiti in October and the pediatrician will be on her first mission with Op Smile. He asked me if I had any advice he could give her to ease her way. So, as an old hand, having done 13 missions (some people on this trip are in their 20+ and 30+ numbers,) here’s what I gave to Bruce:
1. Keep in mind that you are the protector of the children, their voice. If you feel strongly about any issue, in any direction, speak up, even if the surgeons, who “lead the show and speak loudly” say otherwise.
2. The purpose of screening is to accept children for surgery if they are old enough, well nourished enough and healthy. Pay attention to how far the family has traveled (often very far by bus, foot, horse,) and to whether the child has been rejected in the past. Don’t let a child be rejected for a petty reason if you think he is OK. Advocate for him. On the other side, say “no” if you think surgery would be unsafe or unwise. An underweight baby can be helped by a talented speech therapist or perhaps needs an obturator.
3. Remember you are not in the U.S. If a child is seen for screening in a developing country and has a cold, the surgeons and anesthesiologists will reject him. However, if you think he’s a candidate for surgery and may be well in time to have surgery toward the end of the surgical week, give him 3 days of amoxicillin or azithromycin and OK him for surgery with the proviso that he must be clear at his pre-op recheck. It makes no medical sense and you would never do it in your own practice. However, on a mission, it often makes the difference between a child having his lip closed and re-entering village life or going home and continuing to be ridiculed. His family may not be able to make another trip, so bending your pediatric convictions in this way may be worth it.
4. Advocate for kids with disabilities in both directions. If you think they would benefit from surgery, say so. Sometimes they are rejected strictly because of the label – i.e. Down syndrome. Some would benefit greatly and deserve your advocacy. On the other side, think about those with syndromes such as some of the other trisomies, or others who may be vegetative. If the procedure, such as a palate repair won’t benefit the child but will cause a significant time in painful recovery, it may not be worth doing.
5. You are the leader of the pre/post nurses and set the tone for the wards and for how your team interacts with the home country nurses. When you first arrive on the pediatric ward, seek out the head nurse and introduce yourself and your nurses, if possible. I always bring a big box of candy. Thank her for allowing your team to work with her and her nurses for the week and let her know you realize how hard it can be to have such an invasion. Ask her to please let you know right away of any concerns she has or any problems that come up so that you can work them out. Ask her advice often.
6. Be sure your team is working together and not excluding any local nurses or members of the international team whose English isn’t proficient.
7. If you have any great pre/post nurses, ask them to help you get going and ask for suggestions about how to do things. There are some wonderful nurses who have done many missions.
8. Do as much paperwork ahead of time as possible. I always fill out the discharge sheet as soon as the child returns from the OR with the exception of signing it. This includes checking off the boxes for no bleeding, has urinated, no fever, etc., but if it turns out that’s not the case, one can draw a line through that, initial it, and carry on.
9. On the last day, I ask the PC or designee to order a thank you cake for the local nurses and we have a short thank you and goodbye party. It shows our gratitude and the next time an Op Smile team comes, they will have a warm welcome on the ward.
Well, that’s all for this mission. I’m off to Massachusetts, the land of clean water from the tap, soft beds and hot showers. Thank you for your interest in my travels.
