December 13 - Home Again

Sunday, December 13, 2009

I’ve arrived safely back in Detroit today, weary from the travel but energized from the work that was done during my mission. The lengthy flights provided me the opportunity to reflect on the past 2 weeks.

I can’t adequately put into words the experience nor do the photos entirely portray the mission. The friendships and bonds are strong. I consider the team an extended family.

As I drove down I-94 toward Kalamazoo, I couldn’t help but be thankful for the fresh, clean air that I was able to take in. The ability to drive down the street and not see families living on the side of the road in make shift “homes”, nor women digging through the trash finding the next meal for their family or a family travelling and waiting for hours with hopes of having their cleft lip or palate repaired. I was able to take a shower, brush my teeth and drink the tap water without worrying about becoming ill. Although our health care system isn’t perfect, children born into this country have the ability to have their facial deformities corrected at a young age and not go untreated for years or a lifetime. I am privileged.

With the snow on the ground, Christmas music on all the radio stations and discussions about the busyness of the holiday season try and remember what the true meaning of Christmas is all about. It’s not about the gifts wrapped under the tree or the lights adorning our homes. The spirit of Christmas is about sharing your gifts with others and providing a promise for brighter tomorrows.

Happy Holidays everyone and thanks for following me on this adventure.

Day 11 - Last Surgical Day

Five days of surgery, 10 operating rooms, and an average of 5 cases per OR. 212 changed lives and new smiles were created this week! What an amazing feat.

Today I was able to follow a family from start to finish. Little Bora, an 18 month old boy, was born with a severe cleft lip that also affected the nasal structure. His father travelled 12 hours by foot to bring him to Guwahati for screening and surgery. Bora was such a happy little guy. We were able to play together for a few minutes before it was time of surgery. When it was time to go back, we said goodbye to dad and headed back to the OR. Anesthesiologist Liz Bales of Los Angeles, CA and Dr. Dan Pyo of Morristown, NJ utilized their skillful hands to forever change Bora’s life. After 2 hours of surgery, Bora’s surgery was completed and I was able to take him to the recovery (PACU) room to work off the anesthesia. It was here that dad was reintroduced to his son. He looked at Bora and then at the name band – he couldn’t believe this was his son. The expression on his face was indescribable and priceless. He curled up on the bed with his little boy and just stared at him for his hour stay in the PACU. When I went to visit him in post-op later in the day, his father greeted me with hands in the traditional prayer form and said “Namaste” and thank you over and over. The nurse then held a mirror in front of Bora, who just continued to look in the mirror. We would catch a little smile every so often, despite his being tired from the anesthesia.

This story is only one of 211 similar stories. I am so proud to have been a member of such an impactful mission.

Our team worked together so well. Everyone put their differences aside and we successfully and safely accomplished our goal. A fresh team of anesthesiologists, nurses and surgeons arrives tomorrow as we depart. A few have stayed back to help the new team. They hope to accomplish over 250 surgeries next week. This mission was slightly different from previous missions in that the government of Assam did not provide a refuge for families during the mission. Therefore, families had to go home and then come back the night before surgery. Because of the financial abilities of several families, we experienced quite a few no-shows during our week of surgery (approximately 50 no-shows). Operation Smile was working hard to contact those families and provide them with the means to reschedule the surgery for the coming week. Therefore, we hope to see even more surgeries the 2nd week than was accomplished in the first. The overall goal is 500 successful surgeries over the 2 week period.

Tonight we have our final party to celebrate the accomplishments!

My life has been forever changed through this experience. Although I miss home and my family, if I could stay on for the 2nd week of surgery, I would do it without a second thought. To experience the impact this mission has had on the 212 families this week was humbling. Words and pictures can’t accurately describe it – it’s something you have do experience firsthand.

Day 7 - Surgical Day 2

Just a few interesting facts to share with you today:

How the surgical schedule is developed:

•  The first surgical day typically focuses on easy priority 1 cases (unilateral cleft lip) so that everyone gets used to the OR and working together. The 2nd day is a combo of cleft lips and palates. 3rd day is heavy palates as is day 4. Friday, day 5, will be all lips and 1 palate.
• Palates need to be monitored more closely as it is more invasive and bleeding can occur more often.
• Many clefts also need nasal revisions.
• There are V shaped and U shaped palates. U shaped are more challenging because there is less tissue and therefore harder to close. In palates, 2 layers are closed – internal soft tissue and the lingual soft tissue. Lips are closed in 3 layers.

A few other cultural facts:

•  Guwahati religions are dominated by Hindu, Buddhists and Muslim believers/followers.

 Namaskar:

• Namaskar or Namaste is the most popular form of greeting in India. It is a general salutation that is used to welcome somebody and also for bidding farewell. While doing namaskar, both the palms are placed together and raised below the face to greet a person. 
• It is believed that both the hands symbolise one mind, or the self meeting the self. While the right hand represents higher nature, the left hand denotes worldly or lower nature.

Tilak:

• Tilak is a ritual mark on the forehead. It can be put in many forms as a sign of blessing, greeting or auspiciousness. The tilak is usually made out of a red vermilion paste (kumkum).
• The tilak is applied on the spot between the brows which is considered the seat of latent wisdom and mental concentration, and is very important for worship. This is the spot on which yogis meditate to become one with Lord Brahma. It also indicates the point at which the spiritual eye opens. All thoughts and actions are said to be governed by this spot. Putting of the colored mark symbolizes the quest for the 'opening ' of the third eye. All rites and ceremonies of the Hindus begin with a tilak topped with a few grains of rice placed on this spot with the index finger or the thumb. The same custom is followed while welcoming or bidding farewell to guests or relations.
• The black dot seen on the children is a sign of blessing and good fortune and is said to counter the effects of the evil eye.

Garlanding:

• Flower garlands are generally offered as a mark of respect and honour. They are offered to welcome the visitors or in honour to the Gods and Goddesses. The garlands are generally made with white jasmine and orange marigold flowers. They are weaved in thread tied in the end with a help of a knot.

 Bindi:

• A bindi is an auspicious mark worn by young girls and women. Bindi is derived from bindu, the Sanskrit word for dot. It is usually a red dot made with vermilion powder which is worn by women between their eyebrows on their forehead. Considered a symbol of Goddess Parvati, a bindi signifies female energy and is believed to protect women and their husbands. Traditionally a symbol of marriage, it has also become decorative and is worn today by unmarried girls and women as well.

Day 6: First Surgical Day

Monday, December 7, 2009 – Surgical Day One


51 new smiles were created today as the surgical portion of the mission began.

The day started at 5:30am with a wakeup call, breakfast, bus ride to the hospital and then a team meeting. We did a quick run through of what to expect and then headed to our stations. I assisted the OR team as a mock “central sterile” tech, teaching the local nurses proper sterile technique, cleaning and processing of instrumentation. I also had a lot of time to observe each surgery and learn more about each procedure and position a person plays in the OR. It was so enlightening!

Working in the OR’s here are much different than any OR in the US. However, it’s amazing what a team can do to pull together to “Make it work Doctor”! Thankfully I’ve experienced some time in foreign OR’s during my time in international marketing at Stryker a few years ago, so I felt somewhat prepared for what was to come. In all, there are 10 OR’s, eight of which are staffed with anesthesiologists and the other two for local anesthesia, which the surgeon administers and is typically utilized on older patients (over 16 years of age is the rule here). Each OR had a wall of windows, which allowed for a lot of natural light. Supplemental lights were brought as well. The team did their best to keep each area as clean as possible. However, the building is old and with the windows cracked to allow the anesthesia tubes to ventilate, it was a challenge. The autoclaves were primitive but the most important part was that they all worked!!!

The whole surgical process was amazing. Many of the young patients were quite scared coming in to the OR, as you can imagine. Leaving mom and dad – being carried off by a stranger who doesn’t look like you and then being surrounded by strange equipment and people wearing masks speaking a different language! I would be scared too! The child life specialist and the students were able to play with the kids beforehand and get them used to the surroundings, which I believe was a huge help!

Next, the anesthesiologist would go and get the patient from child life and bring them into the OR. They would then have a time out with the OR nurse from our team and discuss the chart. After everything was confirmed the patient was “put under” and prepared for surgery. Photos from various angles and measurements were taken of each and every patient for outcomes research and documentation. Now it was time for the magic to happen.

Less than one hour and a child’s life is forever changed! We had a great team of talented plastic surgeons with us, making each procedure look so easy! We began the day with cleft lip cases, which took about an hour each. In layman’s terms, this procedure is all soft tissue work; cutting and sometimes removing skin and muscle then “sewing” it back together in 3 layers. Cleft palates were at the end of the day and went very smoothly. It’s difficult to physically see the results since the surgical site in the mouth. Nonetheless, these kids are much better off. Their speech is bound to improve. The surgeons were assisted by the local scrub nurses. Education is very important on these missions, and the nurses were able to learn a lot from the team and the surgeons about how to do things!

The OR nurses are amazing and should never be taken for granted! They worked very hard to ensure each table was run smoothly, most running 3 tables at a time. The OR nurse was responsible for getting items, such as suture, instruments, gauze, etc for the surgeon. Some of these items are given (on missions) on an as needed basis. They would open the packages on the mayo stand (table the surgical nurses used to hold their instruments) in a sterile manner. For anyone that’s been in an OR, you know how important sterility is. Be nice to the OR nurse!

After the surgery is complete, the patient is woken up and vitals are monitored by the anesthesiologist. Once the patient is stabilized on their own, they are transported to the Recovery or PACU (post anesthesia care unit) room. It’s here that patients are monitored, vitals are taken, meds are given and more importantly, where mom and dad get to see their children for the first time! The smiles on their faces were precious. Many of them seemed stunned and speechless while others were a bit nervous. They’d never seen their baby with stitches and half awake. The recovery room staff was fantastic, ensuring all the patients were well cared for and monitored during the first minutes after surgery.

Once the patients have recovered they are transferred to the post-operative room with their families. They are given fluids and continue to be closely monitored for any problems. Parents were closing holding their child next to them and couldn’t seem to take their eyes of the new smile before them. All patients and their families will spend the night at the hospital and will be discharged tomorrow morning. Did I mention that all the families are staying on one twin sized bed with about 1 foot of space between them and the next family? And we complain about sharing rooms!

The adult patients are taken care of as well and looked amazing! Babies may pull on the heartstrings, but hearing their reaction made me think again. A 22 year old man said after looking in the mirror, “Now I can get married”. Another 18 year old had never been out of his house, not even for school, before coming for screening because his family was ashamed of his cleft lip. Now he will be able to explore the new world available to him. Talk about impact!

We headed back to the hotel at 8:30pm for a quick dinner and bed while the post-op night team will monitor the patients until 7am tomorrow when we arrive back at the hospital.

It was another amazing day and so fantastic to see everyone’s skills put to work. This is better than any gift – the gift of a smile and new opportunity. The best part is, we get to do it all over again tomorrow for another 50 patients!

Sunday, December 6, 2009 – Free Day


Today patients were informed of whether or not they would be receiving surgery. As I posted before, a new system was tried for this mission in which all patients were individually told whether or not they would be receiving surgery. Those that aren’t eligible for surgery were explained as to why they weren’t candidates for this mission. The majority of non-candidate decisions are due to age (the minimum age is 6 months old). Patients must also be in good health and weight. The good news is the majority were told to come back during the next mission in January for rescreening and consideration.

Only a few had to be at the hospital for this portion of the mission and I was happy not to be one of them. I’d want to give everyone surgery and would have a hard time disappointing a family. Nonetheless, we had a fantastic time enjoying some of the local sites in Guwahati. We visited the Kamakhya temple, an important pilgrimage destination for general Hindu and Tantric worshipers built is 1563. The experience was quite enlightening. Some of the team members that are based in India attempted to explain the significance of all the rituals. According to legend, this is where the goddess, Kamakhya used to retire in secret to satisfy her love with the god Shiva. After she was murdered, this is where her fertility was left. Therefore, the temple celebrates fertility and different forms of the mother goddess. You cannot wear shoes into the temple area. We also witnessed goat (male only) and dove sacrifices. Pigs are also sacrificed at this temple. Many (even the practicing Hindu’s) were aware of this ritual and were surprised to see it occur. Gifts of all kinds were left at different areas in the temple (which isn’t just a building but more of a compound). Incenses filled the air. We were also quite the attraction at the temple as the group was the only foreigners. We’ve been taking so many pictures of the beautiful people of Guwahati and surroundings that we soon became the attraction. Everyone wanted pictures with the foreigners. We’d be walking around and would see that we were being photos by camera phones. Many parents would ask if their children could have their photo taken with us. All of us were happy to accommodate!

After our adventure at the temple, we headed to the Brahmaputra River Side for lunch. Many locals were having their Sunday “beach” day, although there really wasn’t a beach. Picnics, soccer and music filled the atmosphere. We had a great time just hanging out and enjoying the surroundings.

After our late lunch, many team members headed back to the hospital to prepare for tomorrow – surgery day! 50 patients and their families had already been admitted to the ward. It was an amazing site. There are 3 pre/post operative rooms with about 25 beds each. 2 of the wards were for younger families and women while another ward was kept for the adult men. The beds are lined up side by side with about 1 foot of space in between. Families brought their own tapestries and bedding (although the hospital was equipped to provide it as well). Mom, dad and child were all sharing a twin sized bed which became their “home” for the next 36 hours until they are discharged.

I assisted Brittnay, Dalton and Alexander put together the “Smile Bags” – hand made sacks filled with stickers, a note card from donors, washcloth, soap, toothbrush, toothpaste, comb, crayons, paper, a toy and most importantly a mirror so they could see themselves after surgery! It was wonderful to put these bags together and see the love that each person who donated a bag put into its creation. The students then had the opportunity to head into the wards and deliver the fantastic give-a-ways! The children were so excited to get something. Most enjoyed coloring right away. Everyone was so grateful.

It was the perfect ending to the day and reminded me of why we are here – to change lives!

Day 4 - Screening

December 4, 2009


We completed our fourth day of screening today with over 620 patients having been seen by the team! Today, a group was bused in from the Lakhimpur district with high hopes. The adults and children were again so patient and grateful.

Blue Peter, the BBC’s Children’s Program in the UK paid a visit to the team. They sponsor a project every year and this year, Operation Smile was selected. In “Send a Smile” children from the UK were encouraged to collect old t-shirt and create patient surgical gowns by cutting them in the back and placing holes and ties. They were also encouraged to colorfully decorate the surgical gowns. BBC collected thousands of gowns, 1000 of which will be used in India missions. The team had visited Guwahati during the May mission and had some footage that was outstanding. This was originally used to raise awareness of the effort. They have returned to capture how the efforts of so many children are being used in India. By using the t-shirts as patient surgical gowns, the mission is able to provide care for even more patients thanks to the cost savings. Visit the Blue Peter website at http://www.bbc.co.uk/cbbc/bluepeter/getinvolved/appeal/ for more info.

Dr. Bill Magee and his wife, Kathy Magee, RN also paid us a visit. I had the distinct honor of meeting with the Magee’s as well as the Chief of Plastic Surgery in the Guwahati district, his resident as well as the head anesthesiologist at the MMC Hospital and others to visit the new Operation Smile Cleft Clinic currently being built next to the hospital. Although the Clinic is under construction, it was fantastic to visualize the possibilities. I was surprised to see that the entire building was being constructed by hand from the ground up! That’s right – no preformed cement, cement mixers, or cranes. The building was constructed brick by brick by men and women alike.

Even more unique is the fact that Stryker India has stepped up by generously outfitting the clinic with state of the art technology, including the ability to teleconference to the US; providing beds, stretchers, light booms, design concept, etc. This will allow for further education and training of the team that will be based in Guwahati in the coming months. The commitment Stryker India has made is truly amazing and was well received and appreciated by all visiting the site. It was also a pleasure to meet my colleagues from Stryker India working on the project. They have dedicated much time and many resources for this center. The opening is planned for July 2010!

After meeting with the staff it was back to work helping to sort through and prioritize the medical records. We needed to review the files, ensure all information was documented and begin creating the OR schedule for the coming 2 weeks. We also needed to create additional medical records to the high number of patients screened.

We  had the opportunity to walk around the city and many spent time shopping. Shawls, shoes and sari’s were popular take-a-ways! Everything is so affordable, for example, $2 for a pair of handmade traditional Indian shoes! The flower market was also beautiful and very colorful! Some of us even stopped for our own henna tattoos! MaryAnn and I attempted an “after dinner specialty” (according to our new translator friends) from one of the street vendors. We didn’t quite understand what we were getting ourselves into and later discovered what we had was basically chewing tobacco (some sort of nut and leaf combination). Needless to say, it made for lots of laughs on the way back to the hotel. We all enjoyed a casual dinner on the lawn to end the evening.

Tomorrow we begin to stage and set up the hospital area. There is much to do to get ready – prepping the pre-operative area, OR, recovery room and post operative area as well as the child life area. The 2 high school students, Dalton and Alexander, will be helping to clam the children before heading into surgery by playing with they and introducing them to surgical masks and other “scary” equipment the OR offers.

What another fantastic day!

Day 3 - Screening - Guwahati

December 3, 2009 - 9:45pm in Guwahati (11:15am EST)

Today was another fab day!  We screened another 151 patients - that's over 400 patients in 2 days! 

I've had the opportunity to observe each station and its given me a better understanding of the process.  I've also been able to help entertain the children as they wait to be screened.  More importantly, I was able to help with medical records and began to prioritize patients and begin organizing for surgical scheduling.  This took the majority of the day due to the overwhelming number of patients.

This evening we ended the day at 6pm and  had the opportunity to do some shopping.  2 of the translators offered to join us.  They showed us around the fancy bizzare - aka shopping district!  We had a great time finding the best deals and haggling with the shop owners.  It was also a great way to view more of the city.  So many people in such a small space!  Cars, rickshaws and bikes galore! A great way to end the day.

Tomorrow is our last day of screening and then off to surgery!

Day 2 - Screening Day - Guwahati

Dec. 3, 2009 6am in Guwahati (7:30pm on Dec. 2 in Michigan)

The screening process has begun! We arrived at the hospital around 8am on Dec. 2 where we were greeted by over 250 families from just one of the districts in Assam. They were all patiently waiting in the holding tent at the hospital for their opportunity to be seen by the team. I was stunned to see the enormous amounts of people but also surprised to see how patient they all were. The children were so well behaved. Later in the day we would all comment on this. Children in the states would have been fussy, screaming, wiggly and inpatient. Although some of the younger children were a bit fussy at times, they were are quiet, well mannered group who sat in their seats patiently waiting for their number to be called. Ages of patients varied from 1 month to 83 years in age. All were dressed in their Sunday best.

The screening process was eye opening and very well organized. Everyone worked together as a team. Here’s a little glimpse into the screening process:

1. Patients and families wait in the holding tent and are given a number. Groups of 20 are called at a time and walk to the screening area one block away from the holding area. They would again wait for their number to be called.

2. 32 teenage Assamese girls assisted us in the translating process at registration. One by one, numbers are called and families are greeted by the registration team. Operation Smile is gathering extensive information on the families for research. Questions such as mode of transport, distance travelled, water source, cooking method, eating method (fork, fingers, etc), proximity of water source from toilet area, other family with clefts, etc, were asked of each patient. The hope is that this research will assist in better understanding the causes of cleft lips and palates.

3. Next, Patients had a photo taken and attached to their medical record file. Then it was inside to the clinical stations. Translators again assisted the nursing team in completing a medical history. Weight and vitals were then taken.

4. The next stop was to an evalution by the plastic surgeons. The surgeons would evaluate each patient’s condition and grade the priority level of each. The grading scale ranges from 1 to 4 with 1 being the highest priority. Cleft lips are typically given a priority level 1 and palates given a level 1 or 2 depending. 3 and 4’s usually refer to revision surgeries.

5. After the surgeons came the PIT, where each patient is photographed at different yet specified angles to be included in their charts.

6. Patients then visit the anesthesiologists and pediatricians to determine whether or not they are healthy enough for surgery. Unfortunately many of the children are malnourished and suffer from anemia. These patients are referred to the hospital for iron supplements. Families with children that are under 6 months in age are also referred to the Op Smile India contact and asked to contact them in the next 6 months.

7. All patients are then sent to the speech therapist for evaluation and then to the dentist.

8. The lab is one of the last stops, where blood analyses are done.

9. The final stop is with another group of nurses whom check the records for completion and provide instructions to the family to return on Sunday if they are potential candidates for surgery. They will then discover whether or not they will be receiving surgery. Unlike prior missions, each family will be individually told whether or not they will be scheduled. In the past, a list has been posted with names of those who will receive surgery. This new method allows the team to explain why they will not be receiving care. Many think they didn’t get their early enough; the baby cried during screening; they weren’t dressed well enough, etc.

Overall we screened 251 patients in one day – a record for India! We expect the same turnout today as we welcome a more rural district in the state of Assam. Although the day was exhausting, it was also extremely rewarding.

The teamwork was truly impressive. If you didn’t know better, you’d think this team had been working together for years. It wasn’t the chaos I was expecting. Everything worked like a well oiled machine! I feel so honored and privileged to be a part of this team. The care and hope these families are receiving is absolutely heartwarming!

I’ve been bitten by the bug and am addicted. This is an amazing opportunity and I can’t wait to do more for Op Smile.