Second Surgery Day September 7th
Today started out much more smoothly than yesterday in that all the kids had received their hydration and the parents seemed to understand about not feeding their children. The night nurses had tried to estimate when the afternoon surgeries would occur and had allowed the older kids to eat breakfast at 9:00 or even 10:00 if they had a 3:00 pm or later surgery assuming that the actual time would be a little later. Normally this all would have been fine but for one surgeon who pitched a fit in the hall outside the OR when he discovered that the six month old next up on his schedule had drunk three ounces of milk five hours and fifty minutes earlier. He wanted to cancel the surgery because milk is considered a solid food and she had therefore not been NPO for six hours. The mother, having spent all day trying to soothe a hungry, crying baby, was in tears, and I was called to arbitrate. With Quinna’s help, I learned that the surgeon’s main issue was the volume of milk. If the baby had drunk only two ounces, he would not be upset, but three ounces was too much. He would do the surgery, but the baby would have to wait another hour.
He then called for his next patient, a 13 year old girl who was having palate surgery. When he learned that she had eaten two pieces of bread 6 ½ hours earlier, he whirled about and glared at me. This time, though the length of time NPO was satisfactory, the number of pieces of bread was not. Only half a piece of bread should have been consumed. He then asked the girl if she could “fortify herself to withstand the procedure under local anesthesia,” The girl, sensing she was about to miss her chance to have her long awaited surgery, nodded her head, and the surgeon grabbed her arm and ushered her into the OR, followed by an outwardly calm, inwardly raging pediatrician.
Most of you likely have never seen a palate repair, but you might imagine it is not a procedure done under local anesthesia. It takes at least two hours and involves moving around all the tissues in the roof of the mouth – lining, muscle, bone. Luckily, Ken, the anesthesiologist from Seattle who is the team leader for anesthesia and a consummate mediator was listening to exchange just inside the OR door. He gave me a little smile and headshake – amazing what non-verbal communication can actually communicate – “don’t worry, I’ll take care of this, I’ll give her a general anesthetic and this jerk won’t even realize it.” So she got her anesthetic and the baby got done next, but the fallout is that for tomorrow, the last day of surgery, I made an executive decision that no solids will be allowed after midnight and no milk after 2:00 am for any patient. That way, when surgery starts at 8:00 am, no one will have had anything but the 4:00 am water. We’ll keep the others hydrated during the day and there will be some very hungry babies, but at least there won’t be any cancelled surgeries.
About 15 minutes later, an OR nurse brought me a chart of another patient. He had arrived at the OR and had sneezed on the surgeon. The surgeon had decided he might be at the beginning of a cold and therefore cancelled his surgery and rescheduled it for tomorrow. He wanted me to prescribe an antibiotic, one dose to be given immediately and one at 2:00 am. I have learned by now not dig my heels in or let my medical knowledge about the effects of antibiotics on the cold virus (none) interfere with doing what needs to be done to get the child to the OR. Two doses of antibiotic are unlikely to harm him, (though it’s always possible to do harm – allergic reaction, and of course, contributing to the greater issue of global antibiotic resistant bacteria,) and if I say no to the surgeon, the child goes home with his cleft lip unrepaired. I wanted to use amoxicillin, the simplest antibiotic we had, but the nurse told me, “here in China when children get colds, they take Ceclor and that’s what the surgeon wants.” I chose the lowest dose in the range but this time, the floor nurse corrected me saying the middle dose would be better. By this time, I was almost laughing out loud. When you do this kind of medicine, you have to leave your ego at home. You can decide to not compromise at all and make all of your medical decisions just as you would at home, and there is certainly value in that. It definitely will, as in this situation, cause some kids to miss out on their operations, but you will not have practiced “shoddy medicine.” The other choice is to try to practice good medicine and decide case by case if you feel OK bending your decisions to get the child to the OR – weighing harm versus consequences. That’s kind of where I am and what I did, and I assume he’ll have his surgery tomorrow.
Then there’s how you interact with the nurses, local and international. Once I’d prescribed the Ceclor, the head nurse from the ward confronted me, saying, in front of about eight ward nurses that taking antibiotics before an operation put the child at risk for a secondary infection and that I should cancel his surgery altogether. Technically, she’s correct. If someone has been on antibiotics for a long time, it changes the bacteria in their body and may make them more susceptible to post–surgical infections. It doesn’t mean they can’t have surgery, it’s just something for the surgeon to know about and to remember if the patient is ill post-op. It doesn’t apply to this child as he is only getting two doses of antibiotics, but I didn’t want to embarrass her in front of her underlings. It was a bit tricky, but I managed to craft an answer validating her point and thanking her for reminding us all of the consequences of what we, as medical practitioners do, but explaining why I thought this child was OK. Her charges seemed impressed with her and she left beaming, so I think I dodged the bullet. The nurses will get their traditional last day of surgery cake tomorrow to seal the “make nice with the nurses” project.
I’ve been fascinated at the huge difference in how the nurses interact with the parents here. On nearly all the other missions I’ve been on, certainly the international ones, the nurses make regular rounds on the ward, checking when pain medications are due, helping parents give fluids, changing dressings, answering questions. They keep their ears tuned to the ward and if a baby has been unusually fussy, they check with the parent to see if more pain medication is needed or perhaps more help with feeding. Here, no one initiates contact with the parents. No pain medication is offered proactively. The parents, for the most part, are not aware that there is pain medicine available. Parents are walking up and down the hall with crying babies and toddlers all the time, and the nurses never ask if they can help. They don’t offer assistance with feeding. The few times I asked for pain medicine for a patient, the nurse went and spoke with the parent and then returned saying something like, “oh the child is just irritable so we’ll wait awhile,” or “this child says she just wants her mother to hold her.” Quinna says this is the usual way in hospitals in China. The parents are expected to take care of their children and soothe them. The nurses stay in the nurses’ station and do the paperwork.
Each parent is given a glass thermometer as soon as the child emerges from the OR and is instructed to take the axillary temperature every 2-4 hours or if the child feels hot. Complaints of fever are rampant as all the kids are bundled up. No one is willing to unbundle as it is felt to be unhealthy. I’ve decided it’s probably OK as the kids get a dose of Tylenol for their “fever” and therefore some pain relief.
I left out part of the story of our big fancy dinner the other night because it disturbed me but now I’ve learned more and feel OK about telling you. Most will think I’m nuts for being disturbed, but so it goes. Among the dishes presented, this one very ceremonially was a big tureen of “Turtle” soup. In this big bowl was what looked like a whole, small turtle with the head sticking up. I was totally grossed out and could only think of live little turtles various children have had as pets, crawling around. Of course people at the table had to lift it up as they served their soup and make turtle jokes. I have since learned that it was not actually a turtle but rather a type of fish that resembles a turtle. I’m OK with fish soup, even if the fish looks like a turtle, though I still would likely not eat it.
Finally, one job that falls to the pediatrician on these missions is writing out the pre-op and discharge orders, and on this particular one, the post-op orders as well. Writing the orders doesn’t take much time, but on each form, there is a huge demographic section that must be completed – name, age, birthdate, today’s date, weight, sex, site, surgical type, home address….Quinna and I spend a couple of hours a day filling this out on each child. Op Smile needs a big rich donor to computerize and give them a bundle of iPads!
Well, off to the hospital for the last surgical day and many cranky babies.
Today started out much more smoothly than yesterday in that all the kids had received their hydration and the parents seemed to understand about not feeding their children. The night nurses had tried to estimate when the afternoon surgeries would occur and had allowed the older kids to eat breakfast at 9:00 or even 10:00 if they had a 3:00 pm or later surgery assuming that the actual time would be a little later. Normally this all would have been fine but for one surgeon who pitched a fit in the hall outside the OR when he discovered that the six month old next up on his schedule had drunk three ounces of milk five hours and fifty minutes earlier. He wanted to cancel the surgery because milk is considered a solid food and she had therefore not been NPO for six hours. The mother, having spent all day trying to soothe a hungry, crying baby, was in tears, and I was called to arbitrate. With Quinna’s help, I learned that the surgeon’s main issue was the volume of milk. If the baby had drunk only two ounces, he would not be upset, but three ounces was too much. He would do the surgery, but the baby would have to wait another hour.
He then called for his next patient, a 13 year old girl who was having palate surgery. When he learned that she had eaten two pieces of bread 6 ½ hours earlier, he whirled about and glared at me. This time, though the length of time NPO was satisfactory, the number of pieces of bread was not. Only half a piece of bread should have been consumed. He then asked the girl if she could “fortify herself to withstand the procedure under local anesthesia,” The girl, sensing she was about to miss her chance to have her long awaited surgery, nodded her head, and the surgeon grabbed her arm and ushered her into the OR, followed by an outwardly calm, inwardly raging pediatrician.
Most of you likely have never seen a palate repair, but you might imagine it is not a procedure done under local anesthesia. It takes at least two hours and involves moving around all the tissues in the roof of the mouth – lining, muscle, bone. Luckily, Ken, the anesthesiologist from Seattle who is the team leader for anesthesia and a consummate mediator was listening to exchange just inside the OR door. He gave me a little smile and headshake – amazing what non-verbal communication can actually communicate – “don’t worry, I’ll take care of this, I’ll give her a general anesthetic and this jerk won’t even realize it.” So she got her anesthetic and the baby got done next, but the fallout is that for tomorrow, the last day of surgery, I made an executive decision that no solids will be allowed after midnight and no milk after 2:00 am for any patient. That way, when surgery starts at 8:00 am, no one will have had anything but the 4:00 am water. We’ll keep the others hydrated during the day and there will be some very hungry babies, but at least there won’t be any cancelled surgeries.
About 15 minutes later, an OR nurse brought me a chart of another patient. He had arrived at the OR and had sneezed on the surgeon. The surgeon had decided he might be at the beginning of a cold and therefore cancelled his surgery and rescheduled it for tomorrow. He wanted me to prescribe an antibiotic, one dose to be given immediately and one at 2:00 am. I have learned by now not dig my heels in or let my medical knowledge about the effects of antibiotics on the cold virus (none) interfere with doing what needs to be done to get the child to the OR. Two doses of antibiotic are unlikely to harm him, (though it’s always possible to do harm – allergic reaction, and of course, contributing to the greater issue of global antibiotic resistant bacteria,) and if I say no to the surgeon, the child goes home with his cleft lip unrepaired. I wanted to use amoxicillin, the simplest antibiotic we had, but the nurse told me, “here in China when children get colds, they take Ceclor and that’s what the surgeon wants.” I chose the lowest dose in the range but this time, the floor nurse corrected me saying the middle dose would be better. By this time, I was almost laughing out loud. When you do this kind of medicine, you have to leave your ego at home. You can decide to not compromise at all and make all of your medical decisions just as you would at home, and there is certainly value in that. It definitely will, as in this situation, cause some kids to miss out on their operations, but you will not have practiced “shoddy medicine.” The other choice is to try to practice good medicine and decide case by case if you feel OK bending your decisions to get the child to the OR – weighing harm versus consequences. That’s kind of where I am and what I did, and I assume he’ll have his surgery tomorrow.
Then there’s how you interact with the nurses, local and international. Once I’d prescribed the Ceclor, the head nurse from the ward confronted me, saying, in front of about eight ward nurses that taking antibiotics before an operation put the child at risk for a secondary infection and that I should cancel his surgery altogether. Technically, she’s correct. If someone has been on antibiotics for a long time, it changes the bacteria in their body and may make them more susceptible to post–surgical infections. It doesn’t mean they can’t have surgery, it’s just something for the surgeon to know about and to remember if the patient is ill post-op. It doesn’t apply to this child as he is only getting two doses of antibiotics, but I didn’t want to embarrass her in front of her underlings. It was a bit tricky, but I managed to craft an answer validating her point and thanking her for reminding us all of the consequences of what we, as medical practitioners do, but explaining why I thought this child was OK. Her charges seemed impressed with her and she left beaming, so I think I dodged the bullet. The nurses will get their traditional last day of surgery cake tomorrow to seal the “make nice with the nurses” project.
I’ve been fascinated at the huge difference in how the nurses interact with the parents here. On nearly all the other missions I’ve been on, certainly the international ones, the nurses make regular rounds on the ward, checking when pain medications are due, helping parents give fluids, changing dressings, answering questions. They keep their ears tuned to the ward and if a baby has been unusually fussy, they check with the parent to see if more pain medication is needed or perhaps more help with feeding. Here, no one initiates contact with the parents. No pain medication is offered proactively. The parents, for the most part, are not aware that there is pain medicine available. Parents are walking up and down the hall with crying babies and toddlers all the time, and the nurses never ask if they can help. They don’t offer assistance with feeding. The few times I asked for pain medicine for a patient, the nurse went and spoke with the parent and then returned saying something like, “oh the child is just irritable so we’ll wait awhile,” or “this child says she just wants her mother to hold her.” Quinna says this is the usual way in hospitals in China. The parents are expected to take care of their children and soothe them. The nurses stay in the nurses’ station and do the paperwork.
Each parent is given a glass thermometer as soon as the child emerges from the OR and is instructed to take the axillary temperature every 2-4 hours or if the child feels hot. Complaints of fever are rampant as all the kids are bundled up. No one is willing to unbundle as it is felt to be unhealthy. I’ve decided it’s probably OK as the kids get a dose of Tylenol for their “fever” and therefore some pain relief.
I left out part of the story of our big fancy dinner the other night because it disturbed me but now I’ve learned more and feel OK about telling you. Most will think I’m nuts for being disturbed, but so it goes. Among the dishes presented, this one very ceremonially was a big tureen of “Turtle” soup. In this big bowl was what looked like a whole, small turtle with the head sticking up. I was totally grossed out and could only think of live little turtles various children have had as pets, crawling around. Of course people at the table had to lift it up as they served their soup and make turtle jokes. I have since learned that it was not actually a turtle but rather a type of fish that resembles a turtle. I’m OK with fish soup, even if the fish looks like a turtle, though I still would likely not eat it.
Finally, one job that falls to the pediatrician on these missions is writing out the pre-op and discharge orders, and on this particular one, the post-op orders as well. Writing the orders doesn’t take much time, but on each form, there is a huge demographic section that must be completed – name, age, birthdate, today’s date, weight, sex, site, surgical type, home address….Quinna and I spend a couple of hours a day filling this out on each child. Op Smile needs a big rich donor to computerize and give them a bundle of iPads!
Well, off to the hospital for the last surgical day and many cranky babies.
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