On most missions, the first surgical day is a bit chaotic. Both on the ward and in the OR, people are getting to know each other and the unfamiliar facility and it just takes longer to get going. All of that was true this morning, but there were two additional factors that made the first half of the day especially hectic. I’ll get to those, but first, I have to explain how the mornings are supposed to go so you can get the full impact of the disruptions. Surgery is supposed to start at 8:00 am though is often is delayed until 8:30 or even 9:00 on the first day. Since we generally keep going until all the scheduled cases are done, a late start means a late finish. People are motivated to start on time and keep breaks short.
Breakfast at the hotel is at 6:45, departure for the hospital at 7:15, morning meeting at 7:30 and first four kids on the OR tables at 8:00. On the first surgical day, a mock code is run before the first case to remind everyone of what to do in an emergency and to make sure the emergency equipment functions properly. This delays things about 15 minutes, but when the surgeons are ready to start, the first patient for each table must be ready as well. There isn’t any surgical posturing involved; I’ve found that in general, doctors who volunteer on Operation Smile trips have remarkably small egos. Rather, everyone is expected to do their part to make sure the day goes smoothly, and one of my parts, is to keep the supply of patients flowing to the OR.
This mission has four operating room tables running simultaneously with a mix of longer and shorter cases. A surgeon may occasionally ask to do a particular case, but usually they are just assigned a table for the day. Young infants are usually scheduled early in the morning, and short cases such as repairing a unilateral cleft lip are interspersed with longer cases such as closing a large palatal cleft. So, back to the “glitches.” As most of you are likely aware from personal experience or those exciting TV shows, patients need an empty stomach before having anesthesia. This is to avoid having food from the stomach get into the lungs during surgery.
Operation Smile guidelines are to stop solid food for six hours prior to surgery and to have the last clear liquids four hours prior. The night nurses are instructed to make sure the parents understand and abide by the “no feeding” rules. Equally important, especially with the babies, the nurses are supposed to wake everyone at four am and give them water. They must ignore the parents’ and their own preferences to “let sleeping babies lie” and get the fluids in. Without the 4:00 am water, many babies and children will have slept all night and awoken too late to drink before surgery. They will arrive at the OR in varying degrees of dehydration making it difficult to start their IV and trickier to maintain their blood pressure.
OK, I should move on or this whole blog entry will be about a small, though as you might have guessed, significantly irritating part of my day. To be sure to have the patients ready, Zoe (whose name is actually Quinna – I’ll get to that later,) the two recovery room nurses and I got to the hospital at 7:00. Three of the first four patients had been fed milk or bread or rice or sausages!! in the previous 1 ½ hours. None of the four had been wakened for fluids at 4:00 am. As we proceeded to go through subsequent children, trying to find patients who were actually NPO, it became clear that the night nurses, who were not Op Smile nurses but just regular nurses from the hospital here had done no instructing of parents, no policing of feeding and no hydrating. In addition, the Op Smile nurses who would be working on the ward with me during the day had flown in late last night from Shanghai and were sleeping in. The local hospital nurses were trying to help us, but lacked the efficiency of a nurse who knows the Op Smile routines. So, Zoe/Quinna and I frantically (in a guise of perfect professional calm,) went through patients until we had four with empty stomachs and reasonable hydration to start the surgical day.
Once the “start of surgery urgency” settled, I was able to pay attention to the cultural nuances that make these trips so fascinating. On most trips, we put a row of chairs in the hall by the nurses’ station and then call the patients in groups to do the pre-op checks and sign off on their charts for the OR. Patients who are not being checked either stay in their rooms or in the play area where volunteers are entertaining the children. Here, as in screening, there was absolute chaos in the hall. Two chairs were all we managed to obtain from the nurses (despite my traditional offering of a huge box of candy and a speech of gratitude for allowing us to share their ward.) I did my pre-op checks kneeling on the floor at the feet of the mother who held the child on her lap. Surrounding us was a crowd of what seemed like every other parent and child on the ward, leaning in, listening to the questions and responses, watching the exam, Ssshhhing or patting the baby if he was crying, and brushing my hair out of my eyes. At one point, a grandmother tapped me on the hip from behind while I was listening to a child’s heart and slid a footstool under my bottom to the murmured approval of the group. Someone else took advantage of the now established intimacy to move my dangling lariat style nametag around to the back, and thus out of the way. The local nurses clearly disapproved of me being on the floor and kept trying to set up a table for me to sit behind while doing these exams – more formal and designed to keep my “respected doctor” status intact. However, I’ve always preferred examining kids on their parent’s laps, and I’m not really comfortable in that whole “doctor as a god” role.
Fifteen or twenty parents were also gathered around the doors into the OR at all times, giving support to the each parent as she relinquished her child for surgery, or patting or touching an older child as he went in. As a child came out of the OR after surgery, a small mob would follow the child back to the room, help settle the child, hang up the IV, straighten blankets, and lean in very close to inspect the surgical results. HIPPA is not alive or well here
The parents’ response to the child’s pain or unhappiness in different cultures is always fascinating to me, and it is very different here from my last mission which was in Nicaragua. On my Latin American missions, parents generally ask for pain medication as soon as their child complains, and want it repeated as soon as possible. They have a low tolerance for any discomfort their child experiences which made keeping the children NPO long enough to get them to the OR very difficult. Here, the parents clearly want to soothe their children, but seem much more likely to rock, massage, sing, or, in the case of one grandfather, run up and down the hall with the child in his arms while singing. When I explained to one father that his child was thrashing about and moaning because he was still waking from the anesthetic, the father laughed and said he understood but that probably it was also because his child was just “an irritated child” all the time. When I asked another father if his daughter was crying from pain he said no, she‘s crying because she isn’t happy right now.
On the other hand, parents here are fairly quick to give a slap on the arm or leg for transgressions and use what I refer to as the “shock shout” to stop a crying baby. Although I don’t recommend it out of my own sensibilities, it seems quite effective, likely because it resets something. If a baby or young toddler is crying “for no reason,” a mother will give a sharp brief shout, right in the baby’s face. The baby reacts with a startle and intake of breath and stops crying. He may resume crying in a moment, but more often, he settles into quiet wakefulness or falls asleep. Hmmmm. As for the hitting, I was called to see a two year old yesterday who was on the surgical schedule for later in the morning. Apparently he had misbehaved and his mom had, “beat him,” and while crying he had choked on saliva and then coughed for half and hour. When I examined him, he had congestion in his left lung that fortunately cleared with a little inhaled albuterol. No one, parent, nurse nor Zoe/Quinna seemed embarrassed by the incident except for its possible interference with surgery. Clearly the “beating” part of the story was routine.
Before I go on with the day I should clear up the Zoe/Quinna thing. As we were leaving the hospital at about 8:30 tonight, my interpreter turned to me and said, “My name is actually Quinna. Meet Zoe!” Behind us was another interpreter from her program, the actual Zoe who was listed as my interpreter on the list of team members. Zoe’s plane was late, so Quinna was substituted in as my translator. When I erroneously called her Zoe, she politely didn’t correct me – Chinese culture – but now feels “we are friends and I can be open,” and has come clean. Except for feeling like a bit of a dumb jerk, it’s fun to get another example of cultural differences.Quinna is fantastic. She’s a great interpreter and is funny and very helpful – see below.
This is getting long so I’ll just touch on a few other differences I’ve found interesting. The first is that diapers are not used on even the tiniest baby. They wear these wonderful split pants – I’ll try to get a photo without being pornographic, but basically, the crotch of the pants has a U-shaped cutout to accommodate the baby’s elimination. All the parents have damp spots on their clothes from baby pee, and the carry various rags and towels to catch the poop. They are very adept at noticing when the baby is going to go, and I’ve only seen a few “accidents.” As I was doing pre-op checks, I came across one baby with a small rag taped to his umbilicus. Mom explained that he had had diarrhea last week and the cloth was there as a preventative measure against the diarrhea returning. Apparently the local belief is that pressure on the umbilicus prevents diarrhea.
I saw a one year old girl for screening today for a palate repair. She looked like a child who had been taking steroids, with a relatively rounder face for her body. I asked about medications and the mother said she’d been taking a medicine for the past month prescribed by a doctor at a small clinic for “inflammation” for a rash on her face. She didn’t know the name of the medicine but had it with her. She sent the grandfather to the room to get the medicine, and he returned with a twist of paper, and he undid it to reveal an orange powder. The rash was long gone, and although I couldn’t be sure, I suspect that she’d been taking oral steroids at fairly high dose for a month to treat what sounded like mild eczema. I couldn’t approve her for surgery as it would be risky if she were on steroids. She’ll see the hospital pediatrician to try to sort things out, and then return to get her palate fixed.
There’s a very odd practice here about writing the order for the intraoperative antibiotics. There’s an Op Smile policy that all kids get one dose of antibiotic IV at the start of surgery. Kids who are only having lip repair usually don’t get any more antibiotics, and kids with palate repair generally get 24 hours of IV antibiotics followed by 3 days of oral. When the first patient was in the OR, I got a call on the walkie –talkie asking where I’d written the order for the antibiotic. Having never written an order for an intra-operative medication in my life, I was very surprised. It actually makes no sense as I’m not in the OR, I don’t actually give the medication, I don’t know what other medications are being given and therefore might be the cause of possible negative interactions – the list goes on and on. Besides, I don’t think I’ve ever met a surgeon who wants a pediatrician writing orders for medications to be given during his surgery. Nevertheless, this is the custom here. I had to scramble to find all the charts I had completed so far, figure out the doses and write the orders so that the surgeries would not be delayed.
Finally, I am used to nurses who, for want of a better word, coddle the patients. Patients are, after all, "clients" in the US and “have a choice” of where to go for their hospital care. Everyone tries to make the hospital stay as pleasant as it can be under the circumstances. Not so here. The nurses are in charge! The head nurse, fairly young, heavy set, impressive cap, strides up and down the main hallway, literally shoving parents aside and bellowing instructions. In a room she will push a parent aside on a bed to get at a child to check an IV, wake any sleeping child if she wants to check him and shout down any parental objections to her instructions. Her response to requests for pain medication is ALWAYS to tell the parent the child should wait one hour to see if it is better on its own. She explained to me that most children are just tired and will cry themselves to sleep in the hour.
I’m off to the hospital, but a final note: Each parent is given a glass mercury thermometer when their child comes out of the OR and is instructed to take the axillary temperature hourly for the first four hours. All the kids are hot because the ward is hot, the kids are overdressed (culturally) and wrapped in blankets. Almost all the parents report fever to the nurse who then calls me to check the kids. I may break the thermometers or at least hide them.
That’s it for today - yesterday by now. Off for day two which is bound to be better.
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