My Introduction to Mission Surgery: A Diary



 

Andrew Wexler, MD, MA, FACS1

Perm J 2020;24:19.219 [Full Citation]

https://doi.org/10.7812/TPP/19.219
E-pub: 04/03/2020

ABSTRACT

I experienced my first international surgical mission trip in 1993. It was a turning point in my surgical career and has been followed by many missions in many countries over 25 years. Often I am asked by young surgeons what is it like to work on an international mission and what one should expect. Although each mission is different, the sense of accomplishment is always the same and the emotional high one gets from performing the work is always present. Different organizations have different team models. The description here is based on my first mission with Operation Smile, a global nonprofit medical service organization.

INTRODUCTION

In 1993, I experienced my first international surgical mission. It was a turning point in my surgical career and has been followed by many missions in many countries over 25 years. Often I am asked by young surgeons, “What is it like to work on an international mission? What should one expect?” Although each mission is different, the sense of accomplishment is always the same and the emotional high one gets from performing the work is always present. Different organizations have different team models. The description here is based on my first mission, to Kenya, Africa, with Operation Smile, a global nonprofit medical service organization focused on performing safe cleft surgery.

DIARY OF A FIRST MISSION

The equatorial sun rises, and with first light the vibrations of insects and the unfamiliar calls of strange birds fill the room. Yesterday evening we arrived after 30 hours of travel through 10 time zones. At the primitive airport the luggage and equipment was piled high into old trucks, which stirred the fine red dust of the road into our hair and gritted it between our teeth. Our clothes stuck to our bodies with the heat and humidity. We longed for a tepid shower in our old hotel.

Before collapsing into our beds, we carefully taped the holes in the screens and our bed nets and meticulously killed every mosquito in the room. In this part of Africa 1 in every 5 mosquitoes carries malaria, and they feed at night. In the daytime it is the mosquitoes that carry dengue that one must worry about.

This morning I walk out on my balcony, the day already hot, and the smell of burning braziers and garbage is in the air. In front of me glitters Lake Victoria, headwaters for the Nile. Large white egrets and blue-gray storks fill the trees along the lake bank. An African eagle skims the waters looking for fish. Two impala nervously graze in the morning light. I am in Africa, and I am in shock, thousands of miles from those I love, and a stranger in a difficult land. What am I doing here? This is nuts!

At 6:30 am we board the bus, with our knapsacks filled with water bottles, stethoscopes, flashlights, tongue depressors, and little toys for the children. We drive past mud and dung huts, where women prepare breakfast outside over charcoal fires and naked children stare disbelieving at the white faces in the bus. “Mzungu,” they cry (“white people strangers”).

There are few cars, but the roadside teems with people walking, newspapers tucked under their arms or basketed burdens on their heads. We pass small outdoor markets, where women sit in the dirt behind colorful blankets covered with fruit, clothing, and multicolored plastic containers. The day starts early in Africa. Ahead we see a large 3-story concrete building, and an old sign above the rusted iron gate proclaims that this is the provincial hospital.

The bus pulls up to the front of the hospital, where a large banner welcomes our mission team. Medical Director Dr Otieno and the nurse matron, Sister Julia, greet us. Dr Otieno’s brow is covered with sweat, and he apologizes that he is not feeling well because of recurrent malaria. He guides us through the stark concrete hospital lobby and out a back door to a yard, where hundreds of children and their families sit under corrugated-metal shades in the morning sun. There are children with tumors and with burns, but the overwhelming number are infants, children, teens, and adults with unrepaired clefts. The infants are swaddled in colorful African fabrics, and the older children and most of the adults as well are shoeless. They look to us expectantly. We move back into the hospital, where large rooms with wooden tables and dozens of plastic chairs and benches have been set up. This will be the designated screening area, where each child will be seen by a dentist, a pediatrician, an anesthesiologist, a plastic surgeon, and a speech therapist. Medical records will be created and a photo taken of each child. During the next 2 days more than 300 children will be screened for surgery, with every parent and child hoping that their name will be chosen for the surgical schedule. The team hurries to unpack the screening equipment and set up the examination tables.

While we gather important patient information, we also gather the stories of children and adults whose lives have been affected by facial deformity. Their stories are of travel and expectation and hope. There is Aaron, a 10-year-old boy, who has walked 100 miles across the African landscape with Gabriel, his 6-year-old brother who has a cleft. There is Chastity, the 12-year-old girl with a bilateral cleft who was given by her family to a wealthy woman to work as a servant. She is allowed to work only in the back rooms of the house and not be seen by others. Her employer has dropped her off alone at the hospital. There is Grace, age 11 years, burned in a house fire, with her neck and chin fused to her chest, her lower lip contorted against the contracture, her eyes dark and piercing under the shawl she wears to hide her deformities. For 3 months she has lived in the courtyards and corridors of the hospital begging food, waiting for the promise of a team of physicians to come and release her from the social and physical prison of her flesh.

As a boy I was fascinated by a textbook of tropical diseases on the shelf of the public library. Before me in these lines of patients I see the lives affected by those diseases: Malaria, ascariasis, elephantiasis, noma (cancrum oris), schistosomiasis, malnutrition, vitamin deficiency, and so much untreated HIV infection. There are so many clefts and burns that we can fix and so many others whose conditions we cannot change. Our selection process engenders incredible joy in the chosen and disappointment for those we cannot. I must accept the realization that we cannot cure the ills of Africa but only hope to change the life of 1 child at a time.

By the end of the second day of screening, we have seen 300 patients, and the hospital has turned over 3 of their 4 operating rooms (ORs) to the visiting team. Through the doors of the OR are stark rooms, with concrete floors, and central drains still wet from the nightly hosing they receive as a cleaning. We don white rubber boots to go in while the local nurses walk barefooted sloshing through the remnant standing water. The tables sit with torn cushions. Large cranks and gears control their movement, although most don’t move at all. Two rooms have an overhead light, and the other OR has a standing metal lamp with a flexible neck. One room has air conditioning, and the other 2 have open windows with screens.

In the OR corridor sit our large white plastic crates with all the contents of a modern OR inside. What happens next is part magic and part military mission as the OR nurses, anesthesiologists, and biotechnician take charge of transforming these tile and concrete enclosures into modern ORs. What is immediately evident is the expertise, skill, and dedication demonstrated by a group of true professionals, most of whom who have never met before.

By Saturday night on day 3 the full team has arrived. We sit together for the first time crowded into a room with a long table and a ceiling fan, which circulates the tropical air. We are 46 people from 7 different countries with 5 different religions and 5 different native languages. I do not know most of the team members, but what I will come to learn during the next week is that these people are a collection of some of the finest gems in the world of health care. The individuals in the room are bound together by a heartfelt desire to give of themselves for the pure joy of giving. During the next few hours we will be greeted by the local mayor; learn each other’s names; and review in detail the mission procedures, safety regulations, and expectations. We entered the room as individuals from around the world, and we leave the room as a team.

On Sunday our local hosts have arranged a trip for us, a tour by bus and boat to visit the villages that many of our Kenyan colleagues call home. The bus is packed with the Kenyan nurses and physicians, who eagerly point out all the important sites, introduce us to their village chiefs, and laugh as we hesitantly try their local foods. The villages are hot, dusty, and poor, but everywhere are the sounds of laughter and children.

Our trip binds us to the lives of our Kenyan hosts; their culture is warm, friendly, and accepting. They are both happy and grateful that we have come and openly express their gratitude.

Sunday night I can’t sleep. There is the time difference, the knowledge that I must get up very early, and the self-doubt of a young surgeon who hopes that his work will be good enough with so many watching over his shoulder. If I can just have the first case go smoothly and do well . … Am I good enough . … Do I know enough? Why can’t I sleep when I know I must?

Day 5, Monday, I am up before 6, as the sunrise wakes the avian chorus. I quickly wash, dress, and make a final check of my cheat sheet for bilateral cleft lip markings. I was confident of my cleft experience when I applied for the mission, but suddenly I am now not so sure it is enough. The clefts seemed so wide during screening.

We arrive at the hospital greeted by the expectant gazes of children and their parents. Hope and anxiety mix in their faces. As I wait for my first patient to be ready, I am impressed with the efficiency and professionalism of the team members. The nurses, physicians, and support crew are people of extraordinary talent bound by a common heart and sense of caring. Although most have never worked together before, the team operates with military precision.

My first patient is Gabriel, the 6-year-old who has walked 100 miles to be here. Aaron, his brother, holds his hand until we take him through the OR doors. In the OR Gabriel climbs up on the OR table unassisted, holds the mask over his face, and falls asleep. He is intubated, and with a simple povidone-iodine preparation and a single drape with a hole cut in it, we are ready to go. My scrub nurse is a local woman from the Luo tribe; Her name is Hope.

A young Kenyan surgeon, Joseph, is my first assistant and my student. My job during the next few days is to teach him how to do a cleft repair by himself. The room is hot, too hot for me to wear a surgical gown, and there are additional physicians, nurses, and students who press behind me to look over my shoulder. Hey, no pressure, I think and start the procedure, explaining my moves to Joseph while I reinforce them to myself.

An hour later the operation is over, and I am drenched with perspiration, but Gabriel has a beautiful new lip. Outside the OR doors I find Aaron just where we had left him.

“Where is my brother?” he asks. His face looks much older than 10.

“Your brother is fine,” I say. “He has a new lip, and you will see him soon.”

Aaron bursts into a broad smile.

Throughout the day the postoperative ward fills with children. Families crowd around the beds, cradle their children in their arms, and fan them, trying to keep them cool in the sweltering ward.

The ward nurses have the most difficult job of the mission. For 15 hours a day they scurry between the tightly packed beds in the heat of the ward, caring for the postoperative patients who are rolled in from the OR in a constant stream.

Between cases the surgeons drink tea and coffee, and eat rice and fried tilapia caught from Lake Victoria. My least favorite food is ugali, a boiled root starch mashed into a pastelike mix.

By the end of the day we have completed 33 operations. It is 8 pm, and exhausted, we pile into the bus for the dusty ride back to the hotel. Dinner is at the hotel bar, and we drink, Tusker, the local beer. The nights are balmy, but we wear long sleeves to hide from the mosquitoes.

For the next 4 days we will live in the ORs from 7 am to 8 pm, performing as many surgical cases as we can fit into the schedule. Grace will have her neck and elbows released and grafted. Chastity will cry herself to sleep after her cleft repair, overcome with emotion. We find her asleep in the morning, clutching a mirror close to her face.

Throughout the week there is the intricate puzzle of schedule manipulation. The nurse coordinator and chief surgeon match surgeons’ strengths and speeds with the appropriate cases, sliding cases from one room to another to squeeze in another child or maybe 3 or 4 if possible. As surgeons, we learn from each other small technical points, tricks, and techniques, and we teach. During the week I become a better surgeon, and Joseph, my Kenyan first assistant, can now close a cleft lip and a palate on his own.

Our final day, with the last child operated on, there are high fives in the OR and an exhalation of fatigue and relief that 175 children’s lives have been changed without a single complication.

The OR equipment is now folded back into the large white plastic crates. We have so much help from so many local new friends.

That evening there is a party with our team and all those who participated in the mission, as well as the local sponsors, the Kenyan medical professionals, the mayor, and the district health officer, the translators, and the students. The mayor thanks the city utilities manager for the outstanding job he has done in keeping the electricity and water flowing (most of the time) to the hospital.

The next day when we board our international flight, we instantly move from the Third World to that of the First. The plane is new and clean, no red dust covers its seats, the air is cool and filtered, and there is no smell of burning refuse and densely packed bodies sweating in the heat. We leave behind Africa, unchanged except for 175 children whose lives will now be different and so much better.

EPILOGUE

Operation Smile served Kenya for nearly 20 years (before becoming its own nongovernmental organization, Operation Smile Mission in Kenya1). During that time, I returned to Kenya on 4 separate occasions. Over 2 decades we witnessed and contributed to the growth of the local surgical talent, training residents and young surgeons, who are now the professors teaching others. Kisumu, the city of my first mission in 1993, was a small poor city in a neglected western province. Today it is thriving as the third largest city in Kenya.2 Over a generation, Kenya’s health care system has developed the skill set self-sufficiency, and additional revenue streams, that has allowed Operation Smile Mission in Kenya to function independently. Today there are Kenyan surgeons and nurses working on the international mission teams, serving other countries where the need is also great.

Disclosure Statement

Dr Wexler is the founder and president of “Surgiwex” a 501c3 charitable organization that brings training in and instruments for maxillofacial surgery to low- and/or middle-income countries. He has no other conflicts of interest to disclose.

Acknowledgments

Kathleen Louden, ELS, of Louden Health Communications performed a primary copy edit.

Author Affiliations

1 Emeritus, Plastic Surgery, West Los Angeles Medical Center, CA

Corresponding Author

Andrew Wexler, MD, MA, FACS ()

How to Cite this Article

Wexler A. My introduction to mission surgery: A diary. Perm J 2020;24:19.219. DOI: https://doi.org/10.7812/TPP/19.219

References
1.    Quick facts Smile [Internet]. Nairobi, Kenya: Operation Smile Mission in Kenya [cited 2019 Jan 3]. Available from: http://kenya.operationsmile.org/aboutus/facts/.
2.     Mwaniki A. The largest cities in Kenya [Internet]. WorldAtlas; updated 2018 March 14. Available from: www.worldatlas.com/articles/biggest-cities-in-kenya.html.

Keywords: Africa, career satisfaction, cleft palate, global health, international health, Kenya, Operation Smile, Operation Smile Mission Kenya, plastic surgery

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