Today was the third and final day of surgery – shorter than other missions I’ve been on, but not unusual for a local mission. I was up early again, ahead of the team to have the first group of patients ready for the OR before morning team meeting at 7:45. After having hot humid but sunny weather all week, I was greeted by a downpour. My raincoat was upstairs in my bag, and I briefly considered getting it but decided the limited coverage it would provide was not worth waking my roommate. I always carry a large backpack to the hospital with my medical stuff, toys for the kids, extra batteries, toilet paper, and today, small gifts for the nurses. More on the toilet paper later.
In the lobby, there was a bin with umbrellas for sale, and I decided to buy one, but the young girl at the desk couldn’t figure out my gestures, (waving my money, pointing to the umbrellas, pointing to the rain- what’s not to understand???) She finally called and woke up to our Chinese program coordinator who asked her to give me an umbrella. She then dug around behind the desk and brought out a tiny violet umbrella with lace all round the edges. She opened it up and it promptly turned inside out. Seemingly unaware of the uselessness of the umbrella, she handed it to me with a smile and a bow and disappeared through a door behind the desk – all hotel reception desks have them – I call them the “escape door.” At that point, a young man who had been dozing on one of the lobby couches came up and pointed to a car parked in front of the hotel. As I really needed to get to the hospital, and because he (and most serial killers) looked a like a nice guy, I hopped in car.
Once at the hospital, again using gestures, I managed to do the pre-op checks on the first two rows of patients. My interpreter arrived and asked about the NPO status, and with our new draconian rules, everyone was OK for the OR. The only missing piece was the 4:00am hydration visit by the nurses; for some reason that part just wasn’t going to happen.
Before I forget, I have learned to carry toilet paper in my bag on all missions. No matter how modern the hospital, toilets and their accouterments are just not a high priority. Here, as in the hotel lobby, restaurants, etc., the toilets are of the squat type and there are no toilet paper holders, let alone paper. You are expected to bring your own, and once you’ve used it, you never flush it, instead putting it in the basket provided for that purpose. The plumbing is not designed to accept paper, and if you forget and try to flush paper, you are likely to cause a back up which will quickly flood the area where you are standing. Using squat toilets is tricky for westerners both in terms of flexibility and sensibility. The basket full of used paper is changed daily but contributes a heady odor and, when one is squatting, it can be a close-up visual distraction. Closing your eyes might interfere with balance-an essential part of using the toilet. I’ve learned to fix on a point on the wall or door. Anyway, probably that’s more detail than anyone wants, but finally, one must remember not to have any dangling belts or straps.
I’ve mentioned that the babies here don’t wear diapers. They all wear pants or overalls with a U-shaped cutout in the crotch. One little guy almost got me this morning at his pre-op check. His dad was holding him facing forward on his lap but with the baby’s little bottom suspended between his knees. The baby was entertaining me with smiles and coos when suddenly he let loose with both pee and poop. Only my magnificent reflexes kept me presentable, and the usual crowd of parents had a good laugh.
I took some notes as the day went on, and the following are some disjointed anecdotes from observations rom the day.
Most patients who have lip or palate surgery get some swelling of the face post op, and the Asian babies, with their fuller eyelids, often appear to have more swelling of their eyes. This is concerning to their parents, and I spend a lot of time explaining and reassuring. One young couple was sure that their baby’s eyes were painful, despite my reassurances. They came to me yesterday asking if it was OK to put some cream in the baby’s eyes. After further discussion, it turns out that the mother’s sister had gone to her own doctor and explained that her niece had had lip surgery and now had painful swollen eyes, and he had given her a prescription of chloramphenicol ointment to give to the mother of the baby. For the non-medical readers, this is a potential medical disaster in the making. Chloramphenicol is an extremely powerful antibiotic and can have very serious side effects, particularly in infants. It can easily be absorbed from the eye into the bloodstream. As they say on the TV commercials, hidden in the rapid, under the breath full disclosure part, “this may be fatal.” Without saying, “ Don’t use this as it could kill your baby,” I did my best to strongly dissuade them.
There was an 18 month old girl on the ward who cried whenever she saw me. This wasn’t unusual; many babies and toddlers would look at me, even smile or reach out, only to cry if I made eye contact or smiled in return. Their approach is just their way of examining the alien presence – let’s face it, I look like nothing they’ve ever seen. Anyway, this father was determined to get his daughter to like me. He followed me around trying to get her to touch me. Each time he put her hand on me, she burst into tears. Finally, I had to tell Quinna to ask him to stop before he drove her completely nuts.
On most missions I’ve been on, when patients are ready for discharge, they either go home if they live locally or go to a “shelter” which is a hostel or a ward of the hospital set aside for this purpose, to board for the week until their post-op exam. Here, it’s different. Op Smile still discharges them as usual, but they stay on the ward and the hospital doctors take over their care for the week. The patients don’t understand that anything has changed and still consider me their doctor. This is partly because the hospital doctor never comes to the ward, only communicating his orders by phone through the nurses. The problem is that I can no longer write orders and have no way of communicating with the hospital doctor. It’s a frustrating way of doing patient care. For instance, there’s a five year old girl on the ward who had palate surgery on the first day. She refuses to drink and won’t talk to her parents. Her father seems to understand what’s going on and is willing to push the girl to drink, but the mother is frantic and stops him the instant the child cries. She won’t allow the nurse or me to give oral fluids; she’s sure something is dreadfully wrong. This is not the first time I’ve seen this situation, and it always resolves around the third or fourth day when the child’s thirst overrides her resolve not to drink. Of course one can drag it out by providing IV fluids, and the hospital doctors who are now charge have re-started her IV.
I’ve mentioned earlier about the spitting of mucus that is so prevalent here. It seems to be socially acceptable to spit on the street or floor though I didn’t see people doing it in the hospital. Along with this habit is a preoccupation with phlegm. Many parents were worried that their babies had “too much phlegm” after surgery, and that they couldn’t get it up. They wanted medicine to help them. I’m not sure any of them believed my explanation about temporary throat irritation from the breathing tube, but it was all I had so I stuck to it.
Many Chinese people adopt a loud voice and aggressive posture when having a normal conversation. A Westerner, like me, would assume that they are angry or arguing, but it is just their normal way of conversing. The nurses add a bit more volume and a more aggressive stance when talking to patients, and I think this is meant to enforce their position of authority. But even when two people are having a friendly discussion, the impression they give is one of verbal combat. It’s easy to see how intercultural misunderstandings happen based solely on posture, voice, space, facial expression or gesture.
When a Chinese parent is trying to soothe their crying child, they jiggle the baby vigorously, pat them on an arm or leg firmly and or vocalize a loud, “ha, ha, ha.” I’ve never seen a baby quiet to this technique, so I’m not sure how it evolved or why it persists. One grandfather spent literally hours running up and down the hall with his 14month old granddaughter in his arms, jostling her up and down and saying, “ba, ba, ba,” in an attempt to soothe her. She would eventually fall asleep from exhaustion, but never appeared soothed.
Often when I am trying to listen to the baby’s heart or lungs and the baby is protesting and struggling, all three soothing gestures are employed, making the whole exam impossible. Getting the parent to desist, sit quietly with the baby held firmly but gently in their arms for just 30 seconds takes a lengthy explanation and often some physical help in placement of the baby and of the parent’s arms and hands. It’s just such a foreign concept to gather your child in for an exam. I think whenever a child sees a doctor here, they are placed on a table, and held by a nurse while the doctor does the exam. Screaming and struggling are expected and accepted. The idea of examining the child in the parent’s arms so the child will feel safe and comfortable and therefore be able to cooperate or at least not cry, is completely foreign to them.
I observed “the Chinese way” when I went around with the surgeons to remove palatal packs. When children have their palates repaired, the surgeon will often sew a pack made of gauze into the palate provide a pressure dressing. The next morning, the pack is removed by clipping a couple of sutures and pulling it out. When the surgeon swoops into the room with his entourage, one nurse takes the child from the mother’s arms and places him on his back on the bed. Another nurse holds the child ‘s head still while the surgeon opens the child’s mouth and removes the pack. No explanations or reassurances are given before the procedure, just a quick nod to the parent as the child is handed back and the group retreats. It sort of reminded me of an ocean wave washing into the room for a few moments and washing out again, leaving behind a little disturbance and dampness, but otherwise not much change.
I was asked to speak to the speech therapist because the head of the hospital thought I might be able to help him with my background with speech. It was all a little vague, but I said I’d be happy to see him. Today, a relatively young, stocky man found me on the ward and asked if I could come up to his office with Quinna to talk about speech therapy. It turns out that the head of the hospital thought that I was the president of a speech therapy school – just a little misinformation about my affiliation with Clarke Schools. Clarke is all about listening and spoken language for deaf and hard of hearing infants and children, and of course there is speech therapy, but I am not involved in or knowledgeable about speech therapy techniques. It turns out that this “speech therapist” is actually the head and neck surgeon at the hospital, and four years ago, the head surgeon at the hospital called him in and asked him to take on the role of speech therapist in addition to his surgical duties. Since many of the children they see have some articulation difficulties, and they have no speech therapist in the hospital (they are extremely rare in China,) the Chief felt the department should develop their own. This was not a request the surgeon could turn down, so for the past four years he has been trying to teach himself how to be a speech therapist. As he put it, his results are, ”not as gratifying as I would hope.” He was visibly disappointed to learn that I was not the savior he had hoped for, and I felt bad for his dilemma. Operation Smile International is trying to recruit speech therapists to send on the China’s local missions as this is standard on international missions, and perhaps this will bring the surgeon some help.
So, I have two quick observations and a final story to end this day. The first will be better shown once I am home and can put up pictures. Bamboo is used for mop handles and some IV poles and is beautiful. I’ll let you know when the photos are up.
The Op Smile standard for a baby who has had just a lip repair and was breast feeding before the surgery is that the baby can resume breast feeding as soon as she is awake, often in the recovery room. The shape of the breast in the mouth and the action of nursing both serve to pull the incisions together and do not harm the surgical repair. Bottle fed babies must use the syringe or cup for feeding as the firm bottle nipples and the different sucking action required are disruptive. It’s one of the many advantages of breast-feeding a baby with a cleft lip. However, when there is a mission in another country, compromises must be made if the practices of the local surgeons are different., especially if they will be the ones following the babies post-op. Op Smile surgeons try hard to educate surgeons from other countries about the benefits of early return to breast feeding, but changing ingrained practices can be very hard. Here in China, the babies may not return to the breast for 4 weeks. The mothers are instructed to express their milk to a cup and spoon-feed the baby. In reality, this means that the baby will end up on formula as a month is a long time away from the breast, and the mothers don’t have access to efficient electric pumps. Staying in my own lane is REALLY HARD on this one.
And finally, toward the end of the afternoon, Elisabeth brought a young couple to the ward to speak with me. The mom was about six months pregnant and both had obviously been crying. The dad handed me a CT scan of their unborn child and pointed out the obvious unilateral cleft lip and cleft palate. The report below the pictures gave current measurements of both clefts. They had their first ultrasound yesterday and had just had the CT scan “to check on a little irregularity,” this morning. The father explained that they weren’t really worried about the lip as they knew it could be repaired. What he was worried about was how his child’s speech would sound and wanted to know if there was any hope that the child would be able to speak normally. Here they were, surrounded by babies and children and a few teens and adults who had come for minor scar revisions, knowing they would soon be part of this “family.” You’re joining a club that you never even really knew about and are sure you don’t really want to join, but you have no choice. So, Quinna and I spoke with them for a long time, and they listened and watched the babies go by. As usual, a large crowd of onlookers gathered to listen in. I thought about moving us to a private spot, but I sensed they had come there partly to see and hear this. And then I remembered Erin, the volunteer who is on the team to monitor the two high school students.
Erin was born with a very wide unilateral cleft lip and palate and had a beautiful repair and has perfectly normal speech. She has her newborn pictures and some early surgery post-op ones on her phone and has been sharing these with some parents here. Quinna went and got her, and I explained that the parents’ main concern was speech quality and asked her to share her story so they could hear what perfect speech she had. So she stepped right in, opened her phone and began. I just watched the parents and there was this amazing transformation. The dad actually went “slack-jawed,” a term I hadn’t fully understood before I saw it. He saw her newborn pictures and then looked and listened to this beautiful articulate woman, and you could see that he was having trouble putting it together. The mother was more discrete, but she too was clearly awed. After Erin left, the floor nurses who also work with the hospital surgeons who have a cleft lip and palate program here came over and spent almost a half hour describing how the program worked, starting at birth, preparing for the first surgery at 3-4 months. Op Smile can be involved in ancillary ways if needed, but the family lives in town here and can get excellent comprehensive care privately as they have the health insurance they need. The parents still will grieve over the perfect child they do not have, but I think they now can focus more positively on what to do once their baby is born. They also have some real hope instead of all despair. Ava, the Chinese coordinator said that their visit here is extremely rare because due to the one child policy, Chinese parents who are confronted with an abnormal fetus almost always choose termination of the pregnancy. Her comment was, “they will be excellent parents!”
Well, enough for today. Tomorrow is team day and we’ll visit a temple and a jade factory and have the team party.
No comments:
Post a Comment