Day in Beijing

As I write these entries, it’s often either late at night or very early in the morning, and that, combined with the 12 hours time difference makes it hard to know whether to put them in the past or present tense.  Anyway, I pick past for this one as it’s 5:00 am on Thursday the 11th here.  My roommate, Marlyn (turns out her mother forgot the “i” on her birth certificate,” was up at 3:30 to prepare for a 4:30 am ride to the airport, and though she did her best to move quietly, it’s not really her strong suit.  Having Marlyn for a roommate has been a bit of a challenge.  She’s a fantastic nurse, and her boss in the UAE allows her 10 days off each month to do Op Smile missions.  She doesn’t know how many missions she’s done, but apparently she’s well known by the surgeons and anesthesiologists who do the Asian missions and is universally respected.

 That said, she’s a bit like a three year old, no offense to my granddaughter.  She needs constant interaction and attention, going so far as to call my name loudly if I’ve been at the computer or concentrating on my kindle for too long.  She wants me to “tell her a story” each night about various aspects of life in the US, and needs my opinion on her outfits, makeup, choice of shoes, etc.  Finally, she must have the air conditioning on high.  Though the weather is hot and muggy here, our room is always arctic.  No one thing is that big, (well, maybe the AC,) but when every moment of down time is precious, small intrusions begin to grate.  Luckily, Marlyn also has the silly, fun personality of a toddler, so it’s impossible to not like her.  She’s a people magnet, doling out hugs and huge smiles to anyone who drifts into her range.  I could have done worse in the roommate lottery.

We arrived in Beijing from Nanyang at around noon yesterday.  As we flew in I was struck by the sheer number of apartment buildings surrounding the city.  I took some photos from the airplane and will post them on Picasa in the next day or two, but it was a reminder of just how many people live here.  We  were picked up by drivers pre-arranged by Ava, the Asian coordinator.  The plan was to settle into our hotels (we are in three different Marriotts,) and then meet back at Elisabeth’s hotel in central Beijing at around 4:00.  Ken, the anesthesiologist from Seattle, Michael, Marlyn and I are together at the Courtyard Marriott and were driven by a driver we nicknamed the “Angry Bird” for his aggressive, expletive-laden style of driving.  It’s clearly a challenge and learned art form to be a driver in Beijing.  As with the people’s lack of queuing skills, drivers here seem unaware of concepts such as right of way, turn signals, turn lanes, one way streets, crosswalks, or even traffic lights.  A loud horn and a big chassis help, but generally, drivers just pick their route and push the gas pedal to the floor.  One hand guides the steering wheel while the other stays on the horn Angry bird seemed to delight in tailgating smaller cars, scooters and bicyclists, and at one point actually came up behind a man on driving a motorized wheelchair in the bike lane and tailgated him, blasting the horn until the man pulled over.  He then whipped around the man and pulled in in front of him, his bumper barely missing the front wheels of the chair.  As I don’t know Mandarin, I didn’t get to learn any curse words in a new language, but from Ken’s recurring blush, it was clear Angry Bird had quite a repertoire.

We finally arrived at our hotel, and once checked in, we called for a taxi to take us downtown to meet Elisabeth and the students and Erin.  Elisabeth’s hotel is opulent – photos later - in keeping with the overhall done for the Beijing Olympics.  Huge buildings line wide boulevards, though most of the vehicles are electric scooters or bicycles.  Our first stop was a warren of narrow streets lined with food stalls.  In addition to fried dough sticks, fried ice cream balls, noodles, squid, seaweed, buns, and many other traditional snacks, there were skewers of live scorpions for sale.  The customer would pick out a choice stick with five or six wiggling creatures, the stall owner would quickly dip it into a pot of boiling oil,  and voilà, a  crispy treat!  Both John and Chris tried one skewer each – a test of manhood duly recorded by Erin for their classmates at home.

After Snack Alley, we took the subway to the Silk Market.  The subway was quite similar to subways in Boston and NYC.  It’s was little more crowded and there was lots of pushing and shoving that likely would earn you a bash in the nose in the US, but otherwise felt very familiar.  There was a stop in the basement of the Silk Market, a six-story building full of discount shops.  One can indeed buy silk by the yard here in addition to silk scarves and ties, but there are also shops with clothing, toys, electronic, books, most anything you can think of.  There’s a whole floor of Purses and bags, some authentic brand names and some knock offs.  The same is true for watches and electronics.  Supposedly, if you know what you’re looking for and know how to spot a fake, you can get great deals.  I wandered into a few shops and was immediately pounced upon by the salesperson, “Hey lady, do you need a bag?” “Hey lady, see this toy, how old your child, they like this one very much.”  It was what I call “assault shopping,” and since I since I wasn’t actually planning to buy anything, I gave up browsing.  Ken ended up buy two Rosetta Stone programs, one for Spanish and one for Japanese for $50 Yuan (about $8.00) each.  Michael has bought them here in the past and vouched for them being the real deal.

Next, we took the subway again to “the best Peking Duck restaurant in Beijing” where we had made reservations.  The duck is served with pancakes and sauce and condiments and then one is expected to order side dishes.  Having experienced several meals with mountains of food going to waste, we ordered just two veggie dishes and some steamed dumplings.  Our waiter disappeared and came back with the owner, a woman of formidable size and demeanor.  She snatched the menu from Elisabeth’s hands, scanned the table for “the person in authority,” and marched over to Ken.  “Chinese people know what they are doing in this restaurant and they always order several more dishes.,”  said she. When Ken held his ground, she began flipping through the several page menu, pointing out “signature dishes,” all very expensive.  Ken, trying to be conciliatory, told her that we would start with what we had ordered and then, if we were still hungry we would take her advice and order one of the dishes she had recommended.  HA!  She launched into a tirade of outraged Mandarin, and then stalked off.

 I thought we would be gathering our things and leaving, but then Ken translated.  She had said, approximately, “Silly Americans, you’ll have it your own way, of course, and then you’ll need to order more at the end and you’ll hold up my restaurant when I need your table!”  Her declaration would have carried more weight if there hadn’t been an abundance of empty tables and no waiting customers.  In the end, we were quite full and did not require extra dishes.  Ken tipped well and the owner seemed content.

We walked from the restaurant to Tiananmen Square but it was closed for the night, so we headed back to our hotels.  This morning, Ken and Michael and I had a lavish free breakfast from the hotel buffet..  Traditional Chinese foods plus omelets, dry cereal, toast, fruit and very runny instant oatmeal were available.  There was real coffee, my first since arrival – delicious.  In our hotel in Nanyang, they served hot water and little packets of “three in one” which contained instant coffee, sugar and dried milk.  In restaurants, hot water flavored with lemon passes for tea, and if you ask for plain water instead of bottled, it is served hot to show that it was boiled and is therefore pure.  My flight is not until this evening so the driver will pick me up from the hotel at 2:00.  I have the luxury of a quiet hotel room to myself for most of a day.

When I compare this trip to my previous China trip, it’s a little bit apples and oranges.  That trip was to Inner Mongolia which though technically Chinese is culturally very different.  It was also an international trip, the inaugural Op Smile trip to the region, and a political showcase trip.  There were more international volunteers than Chinese volunteers on the team, and there was very little mixing outside of the OR.  Having the international team members to talk with and interact with was nice, but I didn’t really get to know any of the Chinese team members.  Medical students did the interpreting on that mission, and there was one young man who was very earnest and asked lots of questions about the US.  I didn’t have the same feeling of friendship with him as I do with Quinna, but I was able to get a sense of life in Inner Mongolia.

On this mission, with so few international members of the team, we all were forced to interact.  The Chinese members made an effort to show us their lives and used the interpreters to full advantage.  Though there were certainly differences in management styles, in the end we could respect each other and acknowledge that we all had the same goals in mind.  I come away from this mission having a better understanding about the people of China, seeing them less as “really different” and more as regular people from another country.  Inequality there is huge; only a tiny percentage of the population has the means to shop on the boulevard with the 5th Avenue shops or own a car that justifies the wide roadways.  China, however, is moving fast, so if they do distribute their wealth as they make it, maybe they’ll have gridlock some day too.  The biggest difference on this trip for me was having Quinna assigned as my interpreter.  Usually there is a group of interpreters and everyone is competing for their services.  Having one person working with me full time not only gave me the opportunity to get to know her, but allowed us to become comfortable enough to ask each other about our lives beyond the mission.  I’d love to have similar opportunities in other countries.

Well, that’s it.  I’ll sort and post the photos on Picasa as soon as I can, and I’ll put these pages on my blog.  Thank you again for your interest in my adventures.

Team Day

This morning we went to the Wuhou Temple where Zhuge Liang, the “outstanding statesman and strategist of the Three Kingdoms Period” lived and studied.  He was a simple farmer who possessed great wisdom and was consulted by the emperor and advised him in strategy.  The temple was built in the 1600’s and has been rebuilt several times over the years.  Most of the tour was actually not my cup of tea (ha ha,) but there were these amazing 1200 year old trees on the grounds, and others 300 and 600 years old.  They had plaques telling what they were, Catalpa bungei C.A. Mey and Platycladus orientalis Franco for the arborists among us.  There were also some horse statues from the Ming dynasty, around 1600, photos to follow.

After the temple, we went to a jade market.  It used to be an open market with the wares displayed on the ground, very traditional.  However, the central market square is now an empty lot surrounded by jade shops where owners compete for tourist foot traffic.   A few team members bargained prices, more for the experience than for the eventual purchases.  After the market, we went to lunch at yet another traditional hot pot restaurant.  This one was a bit different in that the guests do the cooking in a big pot of broth in a center well in the table.  We were divided into two tables, and ours had all Internationals plus Michael, ethnic Chinese, born and raised in San Francisco.  There is an art to concocting a proper hotpot, and Michael, assured us he could be our guide.  A brief aside about Michael is in order.  We all know people like Michael, Jovial, great at a party and in possession of an endless supply of jokes, mainly on-color.  In general, the “Michaels” I have know are also confident in their knowledge about most everything.  At all of our meals this week, Michael would confidently point out the ingredients of each plate, indicate whether it would be spicy or mild and often give the province of origin.  We soon discovered, often with a mouth full of fiery peppers, that Michael was just a confident guesser.  You’d think by the last day we would have asked for some expert instruction, but that’s the other thing about “Michaels,” they are in general very sweet and nobody wants to hurt their feelings.

Our tray of food arrived, mutton, two kinds of noodles, tofu, potatoes, several kinds of greens, sauces and three raw eggs.  When the broth was boiling, we began adding ingredients under Michael’s direction.  Eventually, everything was in and frothy bubbles covered the top.  We dug in, bringing up a tangle of ingredients that we then had to drape over the edge of the pot and hack loose with our little spoons.  A waiter came by, shook his head and indicated we should skim off the broth, but that was the extent of our help.  Finally we were full, the remnants of our “stew” a rather nasty looking sludge in the bottom of the pot, the table strewn with bits of hacked off noodles and greens.  I wandered over to the other table to check their progress and was astonished to find them dipping noodles out of a pot of pristine broth into clean bowls on a spotless table.  Ken, the Chinese anesthesiologist who lives and works in Seattle came over to our table, looked quietly for a moment, then left and returned with his camera.  After taking a photo of the site, he returned to his table, where there followed an eruption of laughter and exclamations of disbelief.  Of course they all had to see for themselves and trouped over to gawk.  So, how does one cook a proper hot pot?  First you cook the meat, skimming the foam as it forms.  Then you eat the meat, removing any unconsumed pieces before you continue.  Next you add tofu, veggies and egg, all the while continuing to skim if needed and to add more broth from a big pot, conveniently placed on the floor next to Michael.  When everyone is ready for noodles and the remnants of veggies, etc. have been removed, the noodles are added to the now clear broth and are eaten alone at the end of the meal.  As we drove back to the hotel, the Chinese team members cracked an endless stream of jokes about the new American dish, “Hot Pot Stew.”  There is an order to these meals that I finally figured out last night at the team dinner.  Plate after plate of food is brought out, and then, when it seems everyone is completely stuffed, a huge whole fish arrives.  After the fish come the soup, and finally, the rice and noodles.  The noodles signify the end of the meal.

Every Op Smile mission has an end of the mission party.  Some, generally those with a big local donor who owns a restaurant or night club, are big fancy affairs, but most are smaller.  Our team dinner was at the hotel and was modest as befit the mission.  The local dignitaries were there and gave speeches followed by toasts at each table.  Every team member gets a certificate, and the head surgeon and hospital director handed these out.  For the Chinese team members, this was a great honor, and there was much bowing and backing off the stage after each presentation.  I didn’t even consider backing away as I was in heels and there were three steps down.  The photographer had made up the traditional slide show of photos from the week, and it was wonderful to see the before and after pictures along with those of the team at work.  The translators were at the dinner, and I finally got to see the real name of my translator. Like many Asian women who study or work with Americans, she has adopted an Americanized version of her name to make it easier to interact.  Her given name is Quinna.  I was really lucky to have gotten the chance to work with Quinna.  Not only was she an excellent translator, she caught right on to the medicine and was therefore very helpful with explanations to parents and with clarifying Chinese medical terms for me.  We really worked together as a team and though it was only five days, we were together at least 12 hours each day and forged a friendship.  In the little down time we had, she gave me a little window into her life in China and into Chinese culture, a real gift for me.

Tomorrow we fly to Beijing and the next day home.  In all, we screened 101 patients and did 70 surgeries – impressive for just three days in the OR.  I’ll have a wrap up message Beijing.

Third and last surgical day

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.

Second Surgical Day

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.

First Surgical Day

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.

Screening Day

  It’s 3:45 am on Saturday, September 6th, and I am still confused about the time change.  My laptop, which thinks it is still in Massachusetts, tells me it’s Friday afternoon on the 5th, and since this blog entry is about the 5th, we’ll just pretend I got it together and wrote it last night.  In truth, Screening Day was such a zoo that I thought it was a miracle that I managed to Skype with Randy between his morning classes and brush my teeth before crashing.

Since I am in China, Screening Day began with Opening Ceremonies.  The hotel is located downtown, and the hospital is a ten-minute walk past shops and a couple of small parks. Yesterday there was a group of about 20 men and women doing Tai Chi in a small plaza in front of a scooter parking lot.  We were in a big hurry so I couldn’t stop for a photo, but I plan to sneak one in today.  As an aside, electric scooters are the transport of choice here.  They’re lovely in that they zip by nearly silently, unlike their gas driven cousins.  But this very silence makes them a bit of a hazard.  Pedestrians are definitely on their own here, and walking to the hospital yesterday, felt like we had disturbed a nest of silent hornets.

So, back to the Opening Ceremony.  We arrived at the hospital to find a huge welcome banner had been stretched across the entrance.  Of course it was in Mandarin so it might have said, “international team members GO HOME,” but there was a festive air so I think it was a welcoming message.  There were young nurses lined up at each side wearing red ribbons with bright yellow printing across their bodies.  Parents with their babies and toddlers had been herded out to form an audience and were already wilting in the hot sun.  After about 15 minutes of fiddling with the audio equipment and getting all the volunteers and speakers in place, the show began.

 Several dignitaries from the hospital and from Op Smile, China were on the steps along with ME, the designated Important Person from the international team.  There were seven of us in all, and each of the other six came to the microphone, bowed to all directions and then read off long, loud speeches.  I was next to last and had been instructed to give a short speech that included how grateful the international team was to be in Nanyang. With my interpreter, Zoe at my side, I spoke for 90 seconds and said “all the right things.”  My speech was clearly the favorite, solely for its brevity.  Poor Zoe was so nervous she was literally shaking.  For her to be on the stage with these powerful people, TV cameras rolling, with her skills as an interpreter on view for all to see and to likely be judged by her employer was a huge deal. I, of course, was oblivious. It hadn't occurred to me that she would be in the spotlight as well.   As the speeches dragged on, babies began to cry and their parents started slipping away with them, out of the hot sun.  Finally the ceremony ended in front of a much leaner audience, and Screening Day could begin.

Screening Day is always hectic, but yesterday was one of the most stressful ones I have seen.
There is an order to the process with stations the child goes through, registration, history, which includes questions for data collection for ongoing research into causes of clefting, then vital signs.  Next the child sees, in order, the surgeons, pediatricians and anesthesiologists together as we look at similar things, then dentist, speech therapist and lab.  We were in a relatively small room, and the orderly process soon broke down.  The last time I was in China, in Inner Mongolia for a mission, I noticed how much pushing and shoving to get to the front of the line there was at the airport.  The program coordinator of the mission explained to me that there is still a mentality in China of needing to push to the front that is left over from the years when failing to do so meant you starved.  There are programs now trying to reeducate the people on queuing and taking turns, but self-preservation skills are hard to reverse.

I think some of what went on yesterday was due to this mindset.  It felt like the parents were worried that the screening time would run out and we would “shut the door” at some point and their child would not be able to have surgery.  As soon as they were through with vital signs, parents were rushing around the room with their children, shoving their charts forward and trying to sit in the chair in front of any doctor they saw.  No amount of explanation of the process or reassurance that we would see everyone served to calm them.  Finally, the head of the hospital had to pull the authoritarian role and set up marked lines with student nurses monitoring and guiding parents, one by one.  Many still slipped by and pushed ahead, but at least we were able to work.  It was heart breaking and reminded me just how devastating facial deformities are and how desperate parents are to have their child “normalized."

This also came out in terms of “age deviations.”  Op Smile International has fairly strict guidelines on age and weight for when a child can have the lip and palate surgeries.  A child needs to be 6 months old for the lip and 12 months for the palate.  If a child is healthy and heavy enough, and all the physicians and the mission coordinator agree, there can be some “age deviation,” i.e. a five month old lip or 10-11 month old palate.  In the US, the surgeries are done younger, but Op Smile sets these guidelines because in many countries the babies are poorly nourished and the follow up will not be as close.  Having the child a little older and bigger gives a better safety margin.  Yesterday, we had many three and four month old infants come to screening.  At first, the surgeons were telling them they were too young and that they needed to return at six months.  Then one father became upset and said one of the local surgeons who was on the team had told him to come to screening.  This surgeon had trained in France and felt comfortable treating younger patients.

 After conferring, the surgeons decided they would do lip surgery on infants at 4 months if they weighed at least 6.5 kg.  This meant the coordinators needed to go find the parents that had been told to go home and bring them back. It also meant filling out “age deviation” forms to send to Op Smile headquarters.  They have the final say, so we had to do those last night and fax them before the surgical schedule could be completed.  In the end, we put ten 4 month olds on the schedule.  Medically, I’m comfortable with it.  Each of these babies is healthy and chubby, and the follow up here is excellent.  However, the whole process added significantly to the chaos.  Once the four month olds were approved, this surgeon tried to get a three month old on the schedule.  The anesthesiologist from Seattle and I both said absolutely not, and luckily, the surgical team leader who is Chinese also said no.  The three month old was big, but physiologically, younger babies tolerate surgery less well. It’s more risky and there’s no reason the baby can’t wait another month or two.

We saw three children with syndromes that included severe developmental delay yesterday.  None had cleft iip, just palates, and for each, the parents were hoping the surgery would help their speech development.  For each of these children, the speech delay was from the poor brain development, and palate surgery would make no difference.  In addition, having seen enough palate surgery now, I know how difficult the post-op period can be, especially for a child who can’t understand why they are in pain and are not allowed to eat.  Explaining  why the surgeons have “refused” to operate can be hard as the parents often feel the doctors don’t value their child.  It’s more difficult when a cleft lip is involved as the appearance of the child is involved in the decision.

We finally finished screening having seen 96 patients and the schedule was being made up when a couple brought back their 2 year old who had been accepted for palate surgery for me to check his cough.  He had been seen first thing in the morning and had started coughing late in the afternoon.  When I listened, he was wheezing, and when I talked with them, it was clear this was a recurrent problem with exertion or colds.  They said he got “bronchitis” a lot and wanted some antibiotics so he could have surgery.  I tried, through another interpreter as Zoe had gone back to the hotel, to gently talk about wheezing without the loaded “asthma” word, but they became very upset that I wasn’t giving antibiotics.  The surgical team leader came over and heard his wheezing and said it wasn’t safe for him to have surgery this week.  The parents were devastated and stormed out, saying they would see a local doctor.  The sad part is that if I could have convinced them to let met give him a medication for wheezing, he likely could have stayed on the surgical schedule, and perhaps started to get his asthma under control.

At the end of the day, most of us just wanted to get back to the hotel, shower and crash, However, there was a welcoming dinner, not mandatory but necessary to attend. It was given in a fancy hotel by the head of the hospital and local dignitaries. It involved mountains of food, multiple courses and rounds of toasts with wine, beer and sake.  Those of us who don’t imbibe toasted with our sake glasses discreetly filled with water, smiling broadly and pretending tipsiness.  There’s an art to toasting when the dignitary comes to your table.  Your glass must be a fraction lower than his to show respect.  The program coordinator told us it gets comical with two semi-equals each bending lower and lower until they are nearly on the floor toasting.

I ended up not being able to eat much because the dinner was of the style where multiple dishes are placed on a lazy Susan in the center and everybody uses their chopsticks to take what they want and put it on their plate.  Three or four dishes had shrimp, so after awhile, all the dishes had been “contaminated” with sauce from the shrimp dishes.  I didn’t really want to have an allergic reaction and risk treatment by a sake-soaked hero, so I drank my “sake” and nibbled on rice.  We were all offered packs of very expensive cigarettes and fancy lighters as souvenirs.  There are two 16 year old students on the trip who sponsor Op Smile clubs at their high schools.  They are sweet wholesome boys and were trying their best to look cool as the waitresses tried to fill their sake and wine glasses and put cigarettes and lighters at their places.  Their sponsor, a woman whose job it is to watch over them, deftly collected the contraband and showed them how to turn over their wine and sake glasses – “for future reference if you decide you don’t want wine or coffee or whatever.”

Finally, my roommate, Marilyn, the Filipino nurse, is not a big drinker, and was doing the water trick with her sake glass.  She wanted a photo of the biggest big shot who had been introduced as the “Party Boss,” so she went over to the head table and asked if she could take his picture.  He said of course, but only if she toasted with him.  She tried to politely decline, do it with water, wine, but ultimately it became clear he would be insulted if she didn’t do a shot of Tequila with him.  She came back to the table with numb lips and fell asleep in her clothes when we got back to the hotel.

Well, that’s it.  Screening Day is over.  We had to add a table to accommodate all the kids so they are flying in another anesthesiologist. Tomorrow surgery begins.

Addendum to Arrival in Nanyang

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I don’t know how many of you have read about China’s plan to move masses of people from the countryside to the cities, but here in Nanyang, there is a building boom of apartments to support the project.  The buildings are going up at a fantastic rate according to local team members and then buses pull up and disgorge hundreds of families to fill them up.  I’ve attached some photos from our drive in.