August 16: First day on ship

Today is the first day on the ship, and everything has gone very smoothly.  We needed to leave the hotel by 8:15 to be at the dock by 9:00, but the dining room usually doesn’t open for breakfast on Sundays until 8:30.  As a major concession, the  chef agreed to open at 7:55, so we all rushed through breakfast and clamored onto the bus, most with dirty teeth.  At the dock, we waited for half an hour in the already blazing sun for the guy from the boat to get his act together.  He, of course, was sitting under a tent in the shade, carefully checking his paperwork while he chatted with the captain of the “tender” (the little boat that ferries people to the big boat.)  Finally, he gave us a wave and we formed a line in front of his tent so he could check our passports.  As soon as the young women in the group began to reach the front of the line, all the time in the hot sun was forgotten.  What had been a group of young professionals quickly turned into a group of well, groupies.  Whether it was the uniform or his smile, (big white teeth, dimples,) many – not all, to be fair – of the women in the group suddenly wanted photos with him, alone and in groups.  He kindly obliged, leaving some of the men in the back of the line looking a bit sour. 

We finally completed the vetting process and were divided into two groups for the trip to the ship.  I was in the first group, and as we approached the ship, I had unpleasant memories of docking on the lowest deck of the USNS Mercy back in 2010 and having to drag my luggage up 9 decks.  This time, we came along side the ship and were winched up to the main deck.  Of course it meant we had to carry our bags down nine decks to the berthing area, but at least that meant we had a gravity assist.

The day has been busy.  First we went to “berthing” where all 1000 people on the ship, except for the officers, sleep.  Being all together in our own “area” merely means that our beds are grouped together in one part of this vast complex of three-tiered bunkroom.  It’s segregated by sex, but not by day and night workers, so the lights are kept off all the time and no talking allowed.  I’m on the top bunk of my tier, partly by choice and partly by what was left.  As I climbed up to make my bed, one of the young women commented, “ I love that about you!! You just jump up there and climb around, so agile!!”  And I said, “ You mean for someone my age?”  “ Yes!” she said, not at all embarrassed.

Each bunk is assigned a smallish locker so the suitcases sit on the floor.  We’ll see if that’s permitted.

 After “berthing,” we had an information session with a video about the ship. There are 12 OR’s, 4 ICU’s, 4 radiology suites and a burn center. The ship has it’s own oxygen and nitrogen production plants and a fresh water production plant.  After that we went to lunch and managed to sit in an area reserved for officers.  Of course we weren’t aware until an officer came over to tell us.  There was a tiny sign on the table that said, “reserved for E-6.”  The officer said, “Excuse me, you’re fine for today, but for the future, be aware that this area is reserved for E-6.”  Then he smiled, sort of, and left.  Luckily there was a nice young E-6 nearby who explained that E6 was a rank and that we should ignore the first guy.

Since lunch we have been unpacking gear and getting the OR’s, wards, recovery room, etc. ready.  Tomorrow’s patients have arrived and settled on the pre-op ward.  I’ll post photos if I can find and get to the WI-FI lounge.

August 15th: Team Day

Today is the last day before embarkation - an appropriately formal word for the world into which we are - um - embarking.  Having done this once before, I know that our first morning will be taken up with firm instruction about the onboard rules and regulations.  There will also be a lifeboat drill and a "muster practice,"according to our pc, Ryan.  Muster occurs each morning promptly at 5:15 and is actually a roll call/headcount to make sure that no one has fallen (or jumped) off the ship during the night.  Muster is followed by flag-raising and I think the National Anthem - more on all of this once I've actually been through it.  The mess hall opens at 5:00 and closes for breakfast at 6:30, (not 6:31 or 6:32,) so no lingering over coffee.  The first patient will be scheduled for 7:30 which gives me an hour, assuming I eat breakfast, to do the final pre-op exams, make sure all the lab reports are where they belong and write the pre-op orders.  Should be a piece of cake.

Team day is meant to be a day of team bonding, the theory being that people who have gotten to know each other in an enjoyable social setting will be more likely to get along and work well together.  I do think the concept's sound, particularly on these missions where there are so many nationalities involved, and often many languages.  Once the mission starts, the OR's and the wards may be at some distance from each other, and there may not be much chance to interact, so it's helpful to have developed some relationships ahead of time.  The surgeons continue to be a very relaxed approachable group which sets the tone for the rest of the team.

Our team day was held at a beach resort owned by a local Operation Smile supporter.  I've posted some photos on Picasa so you can see how lovely it was.  We spent the day lying on the cabanas and visiting.  The beer-drinkers drank beer and many people swam in the shallow, tepid water. I never quite managed to make it off the cabana's mattress - too lazy and comfortable.  The local vendors of beach wraps, necklaces, bracelets and carved turtles had a field day, but nobody bought the freshly harvested sea urchins -"I'll cut it up right here for you."

After a buffet lunch and more lounging, we returned to the hotel.  Some people are going to a crafts market and out to dinner, but I'm going to stay here and enjoy my last night in this room.  Starting tomorrow, the team will be bunking together.

I don't know what my access will be to WI-FI on the ship.  There is a WI-FI Cafe, but we will only be able to use it at certain times.  I'll do my best to keep posts and photos coming.

Screening Day post script

It's Saturday morning, 6:00 and I've had a good night's sleep.  My roommate never did show up so it looks like I may have traded my large single with a king bed for a slightly smaller one with two queen beds and a kitchenette.  I'm sipping  my Folgers single serving coffee from a stash I keep in the closet with my travel stuff.  I bought it in 2010 before my first Op Smile mission, but since I'm not really a coffee geek, it tastes fine to me.

I wanted to say a bit more about the patients we saw yesterday.  It's always interesting to see where the families have come from and what their medical experiences have been.  On some missions, the in-country team has been traveling for weeks ahead of time, spreading the word to remote villages about the free surgery for cleft lip and palate that is coming.  Many families are unaware that their baby's or child's cleft can be repaired.  They assume the child and usually the mother have been cursed, and they just hide the child away.  The volunteers use word of mouth, posters with before and after photos, and radio spots in addition to going from village to village.  Once they have found the patients, the volunteers arrange for busses to go to pickup sites where the families can gather.  The bus ride may take hours, but at least the families don't have to try to make it to the actual surgery site on their own.  On those missions, we see children and adults of all ages who have never had surgery, and it is amazing to watch when they first see themselves with their faces put back together.  Although all of the trips bring life-changing surgery to patients, I find I am most moved by the ones where the patients never dreamed it could happen.

Having said that, I had a great time seeing yesterday's patients.  Most of them were from Santo Domingo or within an hour of the city.  There were lots of babies around five to six months old who were there for the first surgery to repair their cleft lips, and quite a few one year olds who were returning to have their palate's repaired.  They were uniformly well-nourished as the families, while relatively poor, are able to feed their children.  They have also been receiving the services of the Dominican Republic's Operation Smile program since birth.  They provide nutrition counseling, special bottles when needed, palate obturators to improve sucking, vitamins, etc. Their local program is four years old, and their plastic surgeons and anesthesiologists often travel to other countries on Op Smile teams.

In the photos you'll see a five month old face to face with his mother; both are smiling and clearly connecting.  The two of them were carrying on a conversation, for about five minutes that stopped the whole interview and exam.  He had been a bit fussy waiting his turn, so the mother had started talking to him.  He responded with this wonderful back and forth interchange - watching her intently while she spoke, then laughing, babbling a long string of "words" - perhaps something profound - and then pausing and waiting for her to respond.  Finally, reluctantly, we had to interrupt the exchange and do his exam as the line was backing up.

There was a three year old girl whom you'll see sitting on the floor with her feet up in the air playing with a volunteer's shoe.  She was there for a palate repair.  I take small maracas along to distract the babies while I do my exam, and she took one and began dancing around the pavilion.  She had some great dance moves and entertained the crowd for about 15 minutes before I finally asked her mother to corral her for her exam.

Finally, there were three young men in their twenties and one in his thirties who were there for rhinoplasties.  Many times in poorer countries, patients aren't able to travel back for the "refinements" that children with cleft life and palate would receive in the U.S. or other developed countries.  Evening out a lip scar or in these cases, giving them a nose with symmetric nostrils and a straight septum is very important.  The plastic surgeons were very excited to see them.  At one point, three surgeons were gathered around one young man, peering up his nose and discussing the best approach while he sat there, grinning.  Perhaps the grin was embarrassment, or perhaps he was just happy that three surgeons were fighting over the chance to give him a great nose.  Later one of the surgeons told me that he sees doing these "cosmetic" procedures on the teens just as rewarding as closing the widely cleft lips of the babies.  Those, he said, are also cosmetic, but he sees them as mainly medical as the cleft affects nutrition and therefore general health.  Also, without the surgery, the child will be shunned and unable to go to school, so that surgery, he feels, has many consequences.  When he does the final "touch up" surgeries on the teens, he feels he's finally "making them feel normal, beautiful, handsome," and that is his biggest joy.

Friday, August 14th - Screening Day

We had a 6:15 wake up call this morning for breakfast at 6:30 and departure at 7:00.  It's always entertaining to watch the dynamics around promptness and tardiness at breakfast and morning departure time.  As a rule, the pediatrician and ward nurses are first at breakfast and first on the bus because we know we have to have the kids ready for the OR at a designated time. Even though today was just screening, we are habitual go getters.  The surgeons are generally last and late as they don't really have to be ready until we've already been hard at work for an hour or so.  Now of course that's a giant generalization, and in fact there were two surgeons waiting with the "prompt" group this morning.

Before I continue with a description of the day's events, I need to give a brief summary of last night's team meeting as in at least one sense, it set the stage for our arrival at the screening site.  At the team meeting, there were the usual introductions where each team member states his or her name, specialty and country of origin, trying their best to do so in their native language and in Spanish.  A few team members don't speak any Spanish and a few don't speak any English, but most could stumble through a couple of words.   Of course on missions to China or Uzbekistan, etc, everyone sticks to their own language and the interpreters earn their keep.  I really like this team; there was a lot of laughing and everyone seems to be very relaxed.  The coordinator from the D. R. is Perla, a large young woman with a buzzed head and a topknot who is "There for you!  If you need it, just ask me and I will get it for you!!!"  After general information and "team spirit building" from the U.S. coordinator, Ryan, each team leader, surgery, anesthesia, and pediatrics had a chance to say a few words.  Usually the pediatrics team leader role is filled by the pediatric intensivist, but he won't be joining us until Sunday.  I took the opportunity to give my usual speech about balloons.  In case any of you haven't heard (seen) it or know it well but were really hoping I would include it again, here it is:  Latex balloons were the leading cause of deaths due to choking in toddlers in the U.S between 1997 and 2011.  Toddlers love to put everything in their mouths, and if they bite a balloon and it pops, fragments of the balloon can be blown into their airways, blocking their tracheas.  The American Academy of Pediatrics recommends no latex balloons for children under age eight years.  After I spoke, one of the pediatric plastic surgeons stood up to add his voice, significantly a Dominican voice to the call for no balloons.  Apparently he had recently been part of a futile attempt to revive a child with a balloon aspiration in the local emergency room.  With that sobering speech, the meeting ended and everyone headed for bed.

This morning we drove for an hour to a beautiful private park where screening was held.  As you will see in the photos, the entranceway and pavilions of the park were decorated with at least 100 balloons.  In addition, there were "balloon men" making balloon animals for the kids, including the babies and toddlers.  It's not really possible to fight the whole balloon thing here, but I was happy to see a high level of vigilance among the team members, making sure the balloons stayed out of the kids' mouths.  My hope is that eventually Op Smile will make it a policy to not have balloons on their missions, but culturally, it's a long road.

Despite working in the shade of the covered covered pavilions, the sun was so fiercely hot and the air so humid that my clothes were completely drenched in sweat within the first hour.  I can't remember ever being so uncomfortably hot. The kids, being kids, ran around like little maniacs, oblivious, while the adults all wilted.  We screened 112 patients from infants through a 52 year old man.  Most were from Santo Domingo rather than small rural villages so the babies were, in general, well nourished. We had two interpreters helping us at the pediatrics/anesthesia table, a young woman who just finished medical school and one who will start in the fall.  Both speak impeccable English having gone to an English language school since kindergarten, and both want to be pediatricians.  Though I don't need them for speaking with the parents (yay,) it's wonderful to have them ask all the medical history questions while I do the exam when we are really busy.  They can also fill out forms and write prescriptions. A couple of times kids had fairly technical medical conditions, and I could explain it to the interpreters in English and they could then give the parents a much clearer explanation than I could have managed on my own.  One of them will be with us on the ship, helping on the wards.
We finished the screening about 5:00 and then gathered to make the surgical schedule.  Each patient is given a priority based on Op Smile protocols.  These have been developed over the years and are designed to be sure that babies who need primary lip closure have top priority along with the one year olds who need primary palate repair.  These are followed by other categories such as primary lip and palate repair on older kids and adults, lip scar revisions, palate revisions, rhinoplasties and various other procedures.  There is also a balance to the day to consider so there is a mixture of short and long surgeries on each table and so that the babies go earlier in the day, etc.  I'm not usually involved in all of this, but again, because the intensivist is not here, I took part.

There is always some discussion of kids who fall outside the wight and age guidelines.  For instance, a baby needs to be six months old to have a primary lip repair, and if he is say just five months old  but has a good weight and hemoglobin, he might have his surgery if all of the team leaders agree.  If even one person disagrees, the surgery is not done.  We have six such babies on this mission, all very chubby 5 month olds.  One has a low hemoglobin and will wait, but the others will have surgery.
We arrived back at the hotel around 7:00 pm, tired and hoping to head directly to our rooms.  However, the man at reception had told us this morning that he would be changing our rooms this evening as many of us had been given single rooms by mistake, and he was waiting for us.  So, the first thing I had to do was schlep all my stuff to my new room.  The room is quite nice and so far my roommate hasn't shown up.  I  think she's out to dinner with most of the team at a local restaurant.  I decided to skip the restaurant in favor of that long shower!!

Tomorrow is Team Day, and we are going to the beach.  That's all I know - more tomorrow.  I'll post some photos on Picasa in a bit.

August 13th: Arrival in the Dominican Republic

It's 5:00 pm in Santo Domingo, exactly 13 hours since my alarm rang this morning.  We left home at 4:30 for my 6:45 am flight from Hartford to Santo Domingo with a stopover in Miami.  I'm always amazed by the crowds at our little airport when I'm there to catch the early flights Op Smile seems to favor. With all the usual warnings about a "completely full flight," I was surprised and hopeful to find myself next to an empty middle seat, a clear aisle with the flight attendants busily slamming shut the bins and the rather large gentleman in the window seat snoring away. As I put the armrest down and opened my book, there was a commotion in the front of the plane.  I looked up to see a very large woman leaning heavily on a young male flight attendant with one arm draped across his shoulders.  She had her other hand firmly planted on the back of one of the first class seats in case the man wasn't up to the task of supporting her.  When she'd caught her breath, she started down the aisle, with a graceful hip-swaying walk that belied her size and started chanting, "I made it! I made it! I never ever thought I would but I'm here and you're here, I made it..." She kept looking at her boarding pass, and when she reached my row, she gave me a dazzling smile and said, "this is my seat!"  Before I could get up, she climbed over me and started to sit down.  When her bottom didn't quite fit, she reached over and flipped up the armrest and snugged herself down, taking up half my seat exclaiming,  "Ah! that's much better!"

 Some of you are likely thinking the next three hours were miserable. However, she turned out to be so delightful and interesting that I hardly noticed that I was hanging out in the aisle.  I really enjoyed the flight and her.  The book I was reading was Bad Faith by Paul Offit in which he discusses how some religious beliefs about use of traditional medicine can put children's lives in danger.  I won't use the blog to discuss it other than to recommend it.  Although my seat mate (takes on a whole new meaning,) was not in the medical field, we had an in depth discussion about religions, vaccines and medical treatment of children and parental rights.

  We are staying in a Weston Hotel tonight and tomorrow night.  When I got to my room, it was supposed to be a double  with a roommate, but due to a booking error, there was a king size bed.  I went back down to check with the receptionist as bed-sharing on the wards and in hotels when we've been in small ones is not unusual in Latin America.  However, it turns out I am not to share with anyone and will have this room to myself.  I plan to luxuriate as I'm sure we will be all crammed together on the ship.

Tonight is the team meeting where we will find out more details, but so far what I know is that tomorrow we do the screening and Friday is Team Day - usually an activity that is representative of the country.  Sunday we board the ship, get the OR's and wards set and the patients for Monday's surgery are brought over in the afternoon for pre-op checks.  Monday through Thursday are surgery days with a ½ day on Friday.  Saturday we finish whatever pack up remains and return to the hotel and have the team party that night.  Sunday we fly home.

There are 43 team members plus the project coordinator. Three of the surgeons are from the Dominican Republic, one from Peru and one from Venezuela.  This is the first international mission I've been on where none of the surgeons are from the U.S. - kudos to Op Smile's emphasis on training.  There are 12 team members from the U.S.,  and other countries represented are UK, Bolivia, Brazil, Guatemala, Ecuador and Honduras.  This is my 13th mission, and so far, I think I recognize four people on this list. It's a big organization.

So, that's it for today.  More real news and I hope photos in the newly fixed Picasa tomorrow

Heading to the Dominican Republic

On August 13th I'll be traveling with Operation Smile to Santo Domingo in the Dominican Republic. This will be my thirteenth mission with Operation Smile and my second on a US Naval hospital ship.   Most of my Op Smile experiences have taken place in the local hospital of whichever country we are visiting.  Some are large and well-equipped, but some have lacked even basic things like sheets for the patient beds.  Though the headquarters for Operation Smile is in Norfolk, Virginia, it is a huge international organization with centers and active sites worldwide.  Equipment to conduct entire missions is stored at various sites around the world and can be transported to a smaller hospital, transforming the OR into a modern operating suite.

The US Navy has two hospital ships, the Mercy and the Comfort.  My very first mission was to Sihanoukville, Cambodia on the USNS Mercy in 2010.  The USNS Comfort is currently on an eleven month tour in Central and South America and Operation Smile is just one of several groups on board that will be providing medical care along the way.  The USNavy also conducts medical clinics at each port of call.  There are more than 1000 people on board including the navy personnel and civilians.  To see more about the USNS Comfort's current tour, go to www.http//:southcom.mil.

As usual, I won't know about the availability or reliability of the WI-FI until I arrive, but will do my best to post daily.  I will also put photos on Picasa (link to follow in email,) but there may be restrictions in that the captain of the Comfort has final approval on all photos taken on board.
Thank you for your continued interest in my travels.  If you would like to be taken off of my Blog list, please let me know.