August 21st: Last day of Surgery and Final Day on the Boat

August 21: Final Day of Surgery

Well here I am on the ward at 10:10 pm on the final day of surgery.  However, it’s not because of a glitch in the half-day schedule.  We had just 13 patients today, 12 adults and one 12 year old girl who was the daughter of one of the adult patients.  Most patients had local anesthesia with a bit of IV sedation, and four, including the 12 year old, had general anesthesia.   The last patient arrived on the ward at about 1:00 pm, and the plan was for most, if not all to go to shore on the 5:00pm Tender.  However, only four patients decided to go home today as it turned out several of the patients live several hours by car from Santo Domingo. By the time they reached the shore and were transported home, it would have been quite late.  Besides, the beds and food are great.  The night nurses were disappointed to hear that patients were staying as there is a salsa dancing party tonight in the large entryway of the OR where we have muster.  Bruce and I volunteered to take care of the ward patients for the evening until 11:00 pm so they could enjoy the party.  We’re both happy to have an excuse to skip this event (without appearing to be antisocial,) and they’re ecstatic at the opportunity to flirt with the men in uniform.

 Except for taking vital signs every four hours and making sure pain medications and fluids were being taken care of, it wasn’t very demanding for the first hour.  At that point, a 34 year old woman had an allergic reaction to ibuprofen and a 53 year old man with recently diagnosed hypertension began having a rapid heart beat and chest pain.  We had his pre-op EKG and his cardiologist’s letter of evaluation, clearing him for surgery, and a copy of his normal echocardiogram as well.  The woman responded nicely to Benadryl and fluids, and the man’s EKG tonight was unchanged from pre-op.  Nevertheless, we did decide to consult the Navy cardiologist who reassured everyone. He put the symptoms down to dehydration so I unplugged the monitor and handed over a jug of juice.  Now we’re ready for the nurses to return and go back to being pediatricians.

Just before dinner, we trekked all the way down to the end of the ship to the Fantail to take our team photo. I took a couple of pictures of an amazing cloud formation and posted one on Picasa.  It’s the first time I’ve been outside all week and made me very eager to return to land.  Tomorrow, after we discharge the patients, they will leave on the 9:00 am boat.   We have to be ready to leave on at about 9:30 when it returns.  We'll arrive back on land about four hours before we can check into the hotel, so an excursion to a local craft market is planned.

The last day of surgery is always a half day and usually the patients are older and are having procedures under local anesthesia.  I always enjoy seeing these patients who are leading their lives like anyone else. If the previous day's parents are still around, I often see them together, talking, looking at the babies' faces, pointing to their own scars.  For the most part, I think it's very relieving to these young parents to see happy, successful young and old adults who started life with same challenges their babies are facing.  Of course there are many adults with sadder stories, but in countries with developed or developing cleft programs, more and more infants are being seen early. so their are fewer older kids and adults left untreated.
I'll be up early tomorrow to do the discharges and then pack up for the trip to shore.

August 20: 4h day of Surgery, last full day

This is our last full day of surgery and there were many babies with primary cleft lip repairs on the schedule.  We also had many primary palates so the day has been, once again, long.  It’s 7:15 in the evening and there are still five kids upstairs, four on the tables and one in recovery.  It’s looking like an overall shorter day, but we shall see.  Two things happened first thing in the morning to complicate the day.  First, one of the surgeons from Peru woke up with a badly swollen, red painful ankle. The intensivist, who is always the designated doctor for team members, evaluated him and they decided together to use antibiotics in the hope that it’s a superficial infection and not a joint infection or the beginning of some exotic mosquito born illness.  They also agreed he shouldn’t stand around all day, so we were down to three surgeons.  Since we don't cancel cases for a sick surgeon, the others had to pick up the slack.

The second thing that happened was that no one was able to get an IV into a seven month old who was scheduled as the first case on one of the tables.  Everyone tried including the intensivist.  The problem was that the baby had not had any fluids for over 12 hours and was dry.  Bruce, the intensivist, brought him back to the ward where we pushed juice and water until he was peeing well and then put in an IV to finish his hydration.  Eventually he went back to the OR and had his lip repair done.

This event highlighted one of my pet peeves which is parents refusing to wake their babies for the middle of the night hydration.  My orders for all the pre-op patients are clear, and include fluids for infants and toddlers around four hours before the first scheduled surgery.  It's part of the whole hydration strategy to prevent just this sort of event.  Once the night nurses have explained the purpose behind waking the babies and have supplied the water or juice, they have to rely on the parent’s word, about whether the the fluids are given.  No one wants to wake a sleeping baby, especially not a hungry one who is likely to be fussy, so it is not unusual for parents to ignore the instructions.  When I do the pre-op evaluation in the morning and ask when the child last drank fluids, parents are usually truthful and say the baby  didn't want the juice.  While I understand not wanting to wake a sleeping child, the result is a dry, crankier child, at risk of having surgery postponed.   Our night nurses are great, but last night they were taking care of two kids with respiratory issues and two with vomiting and therefore had to rely on the parents to give the fluids.  Going by pre-op questioning, I'd estimate that at least half of the patients had skipped the night time hydration.   Well, I’ll hop off my soapbox now, but likely you can tell this frustrates me.

Tomorrow there are just 13 patients scheduled, all adults except for one 12 year old.  They are all having scar revisions or surgery or other relatively minor procedures.  Three are also have fistula surgery, operations to close small holes that have developed in previously repaired palates.  These can take a fairly long time to do as there is always scar tissue to deal with.  Nevertheless, the hope is to be finished with surgery after the morning and have the rest of the day to begin packing.  Some if not all of the patients will go home the same day.  The Navy is giving a salsa dance party on the Fantail deck tomorrow evening; don’t ask because all I know is that it’s outside.   Saturday we finish packing our gear and then take the boat to shore.  Saturday night is our farewell party and Sunday we fly home.

On a final note, I asked our liaison officer, April about the bunks, whether there were different sizes to accommodate all the tall men and women on the ship. She said no, all the bunks were the same size and that taller people just fold up their legs.  She also said that sometimes a tall person cultivates a short friend who lets them stick their feet through the curtain at that separates the bunks at the end in order to stretch out.  She also said that this ship's bunks are roomy in comparison to her previous ship.  It had doorways that were more like portholes where you have to duck your head and step over the 12 inch high barrier at the bottom.  She called these doorways "knee-knockers" for obvious reasons.  The bunks there are four inches shorter!
Well, off to breakfast and the wards.

August 19th: Third Day of Surgery

August 19th:  Third Surgical Day

This will be a shorter post as there were no major events.   Being on the boat eliminates many of the things that make the days remarkable.  There’s no going into town to a local restaurant or craft market, and the food is definitely not Dominican. By having the surgery on the boat, not only are we not experiencing the D.R. culture, we’re also not seeing anything close to normal family interactions.  In Latin America, there are generally aunts or grandmas around, and certainly siblings.  Especially in the smaller villages, people live more communally. Here, only one parent or guardian or relative is allowed to accompany each patient due to space limitations.  I am experiencing a foreign culture, but it’s a mix of the U.S. Navy and this altered Dominican Republic. The mothers, and a few fathers, are here on their own in a very foreign environment and most are very subdued, (with a few notable exceptions.) I find I really miss the loud, communal parenting that I’m used to seeing on my Latin American missions.

There’s a routine we go through every morning after discharging the post-op patients from the day before.  As we were doing it, I realized how strange and frantically hysterical it might look to someone not living in this environment.  I’ll try to describe it, and hope to get some photos to post for tomorrow.  I’ve put up some patient photos, some pre and post, and some just uplifting ones.

We have two identical wards with bathroom, showers and a small kitchen between them.  Each has 22 lower and 22 upper bunks.  There are also 20 upper bunks on each side, reached by ladders and are therefore only appropriate for spry parents or teen patients having fairly minor surgeries, so bed space is tight.  Each day there are between 19 and 22 surgeries and we have to "turn over" beds quickly.  The patients for the next day come over on the Tender boat at about 1:00pm and settle into what has been designated as the pre-op ward.   On the other side, the post-op patients are gradually returning from the OR.  The next morning, all of the post-op patients have to be discharged by 8:45 to be on the boat back to the dock by 9:00am.  As soon as they are out the door, the four day nurses, two medical records people and anyone else we can snag and I run around stripping the beds and throwing away trash.  Next, two people sweep using big industrial brooms, and two people follow them with huge mops while everyone else wipes down the mattresses, pillows, etc. There’s a race to get this done before the first patients start returning from the OR to the ward.  Today we were still mopping when the first one arrived.  Eventually, all of the pre-op patients from the other ward grab their sheets and bags and move over to the now clean post-op ward and we help them remake their beds so they can wait there for their surgery. Next, we go over to the now empty pre-op ward and repeat the cleaning process and make up those beds.
Today we had a big cake to thank all the corpsmen who have been helping us – cooking for the parents and patients, fixing things on the wards, getting our laundry, etc.  They are so young and earnest!  A young woman, April, a nurse from the ICU is our assigned contact for any problems, and she comes to the ward twice a day to check in.  The Navy has done a great job with all the details.
True to form the day ended late though closer to 10:00 than 10:30.  The holdup was a three year old with some trouble coming out of anesthesia that kept her in the PACU for a long time.  Since I stay on the ward till all the kids are back and settled, it was another late night.  HOWEVER,  tomorrow is Thursday and then Friday and then we’re done!

August 18; Surgery Day 2

Today was the second day of surgery, and I expected that we would end the day a bit earlier than yesterday.  However, it’s 8:30 in the evening and the last four patients are still on the tables.  We did start on time today after a much more orderly muster, but the 30 visitors slowed things down considerably.  They are from a laboratory here in Santo Domingo, and for the past seven years have done all of the blood analyses for the patients who will be having surgery at Operation Smile missions.  This turns out to be a huge monetary donation as each child gets a screening panel of a complete blood count and blood type, and clotting studies.  I don’t know how much this costs in commercial labs, but I know it is expensive.  Multiplied by hundreds of kids over seven years, it comes to a big savings for Operation Smile.  It’s sort of an indirect donation in that the money saved can then be spent on more missions to help more kids in the D.R.

When the group toured the OR’s, several wanted to see actual operations which meant getting them properly garbed and then explaining the procedures.  When they came to the ward, they were very respectful of the parents’ and kids’ privacy, but had many questions for us about working on the ship versus in local hospitals.  It’s clear they are really interested in and devoted to the Op Smile mission.
Otherwise, things went smoothly today.  I had one boy whom I saw at screening on the 14th with chest congestion.  As is typical procedure, I treated him with antibiotics for three days and saw him back today for recheck.  He was no better, so I gave him a nebulizer treatment with albuterol, (an asthma medication,) and he cleared right up.  After discussion with the pediatric intensivist and the team leader for anesthesia, we decided to treat the boy for 48 hours with steroids and frequent nebulizer treatments and see if he has enough improvement to have surgery.  The thought process is different on these missions than it is in the US or other developed countries.  The child's safety is the first priority, but you also have to take into account the child's opportunity to have the surgery done.  The international team only visits the DR twice a year, and this boy is already four.  His speech patterns are being adversely affected by his open palate, so he needs it fixed.  His undiagnosed asthma is likely being affected by the palate as well as he aspirates when he eats.  Finally, this family is from a small village, a day's travel from Santo Domingo.  The father came with the boy, leaving the mother home with the five older and younger children.  So, I'm keeping my fingers crossed.  The next and possibly harder problem will be figuring out ongoing asthma treatment after he leaves the ship.

There were a couple of interesting stories on the ward today.  A seven month old boy is here with his father; mom is home with the other six kids ages 18 months through seven years.  This boy, Anderson, is breast feeding, and it doesn’t look like Dad has ever changed a diaper.  However,  he’s clearly very dedicated to his son and to being the parent to take on this challenge.  He was doing his best today to feed Anderson juice and formula with a syringe post-op, but was clearly overjoyed when a mother in the next bed with a six month old offered to breast feed Anderson along with her own son.  Both Anderson and his father were in heaven, and the other baby didn’t seem to mind sharing.

There’s an 18 month old girl here for repair of her palate.  This morning when I did the pre-op exam, her mother asked if I could give the child a sedative so that she would sleep all day after surgery.  I tried to tell her, gently why that wasn't a good idea, but she interrupted me to explain that her mother usually took care of the child because “nobody else can handle her.”  She went on to tell me at great length that I would soon see that the child was  "unbearable and out of control," would refuse to eat or drink or take medicines and that eventually I would be won over to her request.  I, of course, remained polite and smiling, reminding myself in a never-ending loop that parents who seem overbearing are usually just scared.  Luckily, though the mother started out her stay repeating her mantra to whoever would listen, our nurses gradually won her over.  They spent lots of time at her bedside, helping her give the girl fluids, modeling calm but firm guidance, etc.  She had a brief but wild regression when we needed to re-tape the IV during which she sang the ABC’s over and over at high volume and chanted, “ mommy loves you.”  When we were finished, she told me that she decided to have the child's palate repaired because it was clear to her that the child was a "genius linguist."  Mom says the child knows her ABC's in English, Spanish and French, all self taught, and that without the palate surgery, she was unlikely to get a job as an interpreter, the obvious choice for a child with her skills.  Hmm.

 Bruce the Intensivist showed me a shortcut to the PACU that cuts off the long hallway but involves using a brown-railed stairway.  This may seem inconsequential, but having relied on  using only red and orange rails to keep myself from getting lost, it took real courage to head up those brown-railed stairs.  Still, the shorter passage drew me when I was on my 33rd trip, and on my fourth pass through the shortcut,  I went up one extra floor and ended up barging into a men’s ward.  It looked almost identical – just full of men.  There was sort of a shocked silence, all of us staring  until I turned around and walked out, gracefully!

 Oh, the barging: All of the doors on the ship are extremely heavy. I'm sure it has something to do with it being a boat - ?sealing off compartments to keep the whole boat from flooding if one part is full of water?  Anyway, to open a door, I have to either throw my whole body weight against it, hence the barging in, or grab the handle and use my weight to pull it open if it comes toward me.  So, my workout on this boat includes cardio strength training.

I’ll end with two attack stories.  The first is what I call attack laughter.  There are people, usually quite nice in all other respects, whose laughter is very loud and abrupt.  They often laugh when others only feel fit to let out a small giggle, and therefore, their laughter is not muted by the crowd.  This laughter startles those around them, sometimes strongly, and thus the moniker, ‘attack laughter.’ There is a lovely nurse on the team who does this, and I was unfortunate enough to be sitting right in front of her on the van ride to the beach on Team Day.  By the time we got there I felt like I'd been mauled.

The second attack story involves hand sanitizer.  There are containers of Purell sanitizer all over the ship, six on each of our wards.  They are attached to the walls, and if you walk by too close to them, they shoot out a stream of foam.  Thus, I have dubbed them ‘attack sanitizers,’ and I have been sanitized more times than I can count.

Well, it’s 10:57, I’ve left the ward and am in the WIFI lounge.  The rest of the week, there are fewer palate surgeries so the days should be shorter.  Here’s hoping!  I'll try to post more photos in the morning when the WIFI is faster. Please ignore typos.

Addendum: It's 4:30 on the 19th, another short night.  I've put up some pre and post photos. One pair (none arranged side by side) is of a 30 year old man, alone in the pre and with his brother, who accompanied him, in the post.  There's also one of him with me.  His nose is bandaged, but I think you can see how much he'll love the result.

August 17th: First Day of Surgery

It’s eight pm and the last three patients went to the OR about half an hour ago.  There were only 19 patients today, down from 22 on the schedule due to two no shows at the dock and one with a fever and cough.  I had a brief moment of hope for an early finish, and that was likely enough to cause the jinx that has patients still on the tables at this hour.  A late start, having only one PIT(photographer who does intra-operative photos,) and some complicated cases combined to make the day move slowly.

So, the late start was due to having to learn how to do our first muster.  At  6:30 we gathered in the big open area at the entrance to the OR’s and had our morning meeting.  I had already been up for a few hours,  trying to post photos and seeing the pre-op patients.  At 6:45 the officer of the day arrived and asked us to form into three lines to facilitate the muster.  At first she said she would be calling each name and asking us to respond, but then changed her mind and just went over the list with Ryan, allowing him to look over the group and say yay or nay after each name.  When we were done, the Navy nurses and techs who are assisting us in the OR lined up to do their muster.  They really should have gone first so we could watch them,  and maybe we would have done a better job.  Their lines were straight, and they stood at attention.  After each name was called, there was an easily heard, “HERE, Ma’am,” and when they were done with muster they recited the Navy creed.  It was very impressive.  After muster, they held a mock code in the PACU for all the OR people, something OP Smile does anyway, but a bit more elaborate since it was done Navy style.  The first patients didn’t get on the tables until 8:30, an hour later than planned.

The single PIT contribution to the problem is more complicated.  All patients have a precise photographic record of their surgery.  Usually there are two trained medical photographers who are in the OR’s and are called by the surgeons at various stages to document the surgeries.  When there is only one PIT, as they are so lovingly called, the surgeons have to wait their turn.  This definitely slowed the flow today.  Finally, there just happened to be several kids with complicated problems.  What was really impressive about the day was how good-natured the late patients were about the wait.  The last three to go to the OR were a 6 year old girl, a 13 year old boy and a 30 year old man.  They sat and worked puzzles, colored with crayons, played cards and raced matchbox cars for the last two hours.  My patience with the delay had long since been used up, but they seemed to have a great time.

Around noon, I ate a quick lunch and then went down to the berth area and found a middle bunk on the side against the wall.  It looks perfect so I’m hopeful for a good night’s sleep tonight.  If the WIFI cooperates, I’ll send photos in the next day or two.

Today I’ve been counting the number of times I go up and down the stairs from deck to deck.  So far I’ve made 38 trips for various reasons, a few have been from bottom to top or vice versa, but most are in a pattern between the OR and/or PACU and the wards, or from the wards to the dining (mess) hall.
 So, the layout of the ship, which  seems smaller every minute, is as follows:

On the top deck is the mess hall and the NGO business lounge where the so-so WIFI can be found.
Two decks down, following the stairs with the red rails and being sure to come out to the mint green walls is the deck with the OR’s and PACU.

Two decks further down but at the other end of the ship, down the stairs and following the orange rails, one finds the pre and post op wards.

  To get to the berths, which are down four more decks, you must first climb up the orange stairs to the OR deck which is one of two that runs the full length of the ship, go down to the red stairway, and descend to the very bottom of the ship.

  In the morning, if you are going directly to breakfast, you can climb all the way up from the berths to the mess hall.  As I was up too early for breakfast this morning (5:00 – 6:30,) I climbed to the OR floor,  starting at(deck 9, climb too deck 3,) then down to the wards, (deck 3 to deck 5,) then later back up to the OR deck (deck 5 up to 3,) across the ship to the red stairs and then up to the mess hall, (deck 3 to deck 1.)  I’m sure they’re not called decks 1-9, but it keeps things clear to me.  By the end of the week, I should be in much better shape.  I don't know which other deck goes all the way across, but as I don't use it and I don't want to get lost, it's off my radar.

Tomorrow, there will be 30 visitors on board from some foundations that support Op Smile.  The remaining 20 will come on Wednesday.  It will definitely add to the chaos, but their support is what drives the missions.  Donors generally are very respectful of the patients and our work schedule on these visits, but that many extra bodies will be interesting.

The surgical outcomes have been really beautiful today.  Once again, I'm so impressed with the level of skill and artistry of the plastic surgeons on these missions.

Finally, the 30 year old man’s surgery was complete, and I went up to the PACU at 10:30 to see him before heading to bed.  The surgery had been planned as a lip scar revision, but the plastic surgeon on that table was Henrique who is a highly regarded surgeon from Peru.  He decided that this man deserved his best, and even though it was late at night after a long day, he did a beautiful rhinoplasty in addition.  The younger brother who has been with the patient on the boat all this time, was brought to tears, as were most of us. Very cool.

While all this was going on, I began to notice that the floor was moving much more than it had been earlier. It turns out there had been big thunderstorms and heavy rain all day, and now there were big swells rocking the boat.  It’s a little strange to be on a ship and totally unaware of the weather.

As an addendum, it’s 4:30 on the 18th and my new bunk is great – quiet and cozy.

First night on board

It's 4:15 in the morning on August 17th and I finally gave up trying to sleep.  I'm in the NGO lounge trying to take advantage of it's empty state to upload a few photos from yesterday.  WIFI is clearly going to be a challenge.  Last night was a disaster.  My bunk, which is on the top of three tiers, is a coffin-like space.  I can't sit up and my head and toes can touch the ends if I stretch.  I can't roll over without careful maneuvering to avoid falling over the edge to the deck below.  I was separated from the woman in the 3rd tier bunk in the row next to me by a panel of thin sheet metal.  She kept snuggling up to the panel which flexed and twanged loudly.  I have two snoring neighbors and a cold air vent blew my curtain open and blasted my head all night. After awhile I started thinking about being on the lowest deck and how that must mean we were under water.  Next I was imagining sounds of water sloshing around on the floor - well almost.  Anyway, you get the picture.  At some point today I need to search the designated Op Smile bunks and see if there are any unclaimed, first level, wide, soft, quiet ones elsewhere in the "female berthing area."

So to clarify the morning routine: We have no wakeup call, but have to be at muster (headcount) in the OR area at 6:30.  The Navy takes this seriously, as they should, to be sure everyone on the boat is accounted for.  There are musters all over the ship for various groups.  Surgery starts at 7:30. Breakfast is from 5:00 to 6:30. There are very limited showers and bathrooms. So, as Ryan, our pc put it, "get up at whatever hour you need to in order to be ready for muster at 6:30 and the OR at 7:30."  None of this looks like it will be a problem for me.

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.