Heading home...





Michael Fritz

Well, today is the day we pack up and head to Accra for our flight to Amsterdam. There are so many thoughts and experiences swirling around in my head that when the early morning bird outside my room began to call at 5am ("wheecher-wheecher-wheet"), I couldn't go back to sleep. So much has happened, so many lives touched, so many lessons learned.

Last night was our U.S.-Ghanaian Team dinner at our hotel, the Rexmar. The Ghanaian doctors and nurses shed their blue hospital clothes and came dressed in finery. The head of Komfo Anoyke Hospital was there, thanking us for our work, and we cheered each team member as he or she came forward to exchange gifts. Our Ghanaian counterparts gave us strips of kente cloth with the Komfo Anoyke Hospital logo on them, so we all looked a little "native" by the end of the evening.

Earlier in the day, I followed the surgeons around on their morning rounds. It was a chaotic scene, filled with kids shouting, families milling about, and bags of supplies being loaded on women's heads. With Kofi Boahene and Felicia Addae (two CSI team members originally from Ghana) interpreting, the surgeons examined each child, took pictures for records, and made sure each parent understood post-operative care. One of the beauties of cleft lip & palate surgery is that most patients can go home the next day, so only one night is spent in the crowded conditions of the hospital. Floor nurses Jan Gauger and Kathy Goedde have been coping all week with just 13 hospital beds (for 15 plus patients, so some have to double up) in an open ward of perhaps 100 beds: no air conditioning, one bathroom way down another hall, and a noise level that would drive most people around the bend. Yet a father from another part of the ward came up to them the other day and praised them for their attentiveness and compassion. "I have been watching you, and I can tell you care so much for these little children," he said. Before leaving, each family received medicine to treat iron deficiency and mosquito netting to guard against malaria, which was present in many of our patients, and kills 17,000 children a year here in Ghana. What a feeling of accomplishment, to discharge so many healthy (if somewhat sore and dazed) children with their beaming parents. "You have made me so happy," said 17-year-old Vivian, "thank you so much."

Down in pre-op, as the last patients waited for surgery, we all got a little silly. A paddle-ball contest broke out and everyone got in on the action, including Laura, a British medical student who has observed the CSI team all week. Matilda, the head Komfo Anoyke surgical nurse, proved to be most accomplished, achieving 15 bounces in a row. We began giving away some of the smaller toys and packing up the rest to use on other missions. Then, as surgery finished, we tackled the laborious process of packing anesthesia machines, surgical instruments, and other valuable pieces of equipment. The less expensive supplies that are easily obtained in the U.S. we leave behind to help our host hospitals.

So, our time here is almost over. I am ready for home: for my own bed, for the feel of my dog's ears, for the voices of my children--and for fresh vegetables! But I will miss so many things here. The Ghanaians we met love to laugh and always take the time to stop and visit, to smile, to touch. I will miss the music of their language, their fluid movements, the color they add to every aspect of their lives. They live with so much less than we do, and yet in many ways they are savoring what they have.

One final snapshot: After all our cases were packed up and wheeled out of the pre-op area, the rumpled iron beds lay empty. But up above them, on the windows, were taped all the pictures the children had created: fish, birds, and butterflies, bright with the colors of hope.

Ready to go home!


Making rounds in post-op


A mother waits for her child after surgery


Anaesthesiologist Raj Sarpal gets to work

enjoying the toys


Father and child waiting


Sleeping in post-op


Cathy Goedde keeps them smiling

It was another wild day in pre-op today, with more screamers and yet more interviews!!! Newspapers this time. We are thrilled with the media involvement, however, so we can't complain. Every day we are hearing more stories about the unnecessary suffering surrounding cleft lip and palate here in Ghana. Another surgical resident, Dr. Samuel Ansah, told us that the divorce rate is much higher in families with a cleft baby, since the husband blames the wife and often abandons her. We had a patient today, 12-year-old Sarah, who did not attend school and couldn't read. Many cleft children are either kept from school because of embarrassment, or are prevented from attending by the schools themselves; other families refuse to allow their children to be in the same classroom with a cleft child. All this media attention will just underscore the ease with which this this facial deformity can be fixed, and bolster the efforts of the local cleft team at Komfo Anoyke. It will help "break the cycle of ignorance," as Dr. Ansah put it.

I wanted to mention something about the food we eat here. For breakfast at our hotel, we are served platters of fresh local fruit: pineapple, melon, papaya, and bananas. The bananas are especially delicious, which is no great surprise because banana trees are everywhere, and huge bunches are carried past us every day on the heads of women. We also have eggs, toast, and the local version of sausage and bacon, which have a somewhat stronger taste than at home. Coffee is hot water mixed with a little packet of instant Nescafe. Sigh.

Lunch is brought to us at the hospital from the kitchen there by a dour-faced, golden-hearted woman named Sarah, who fusses over us like a mom. The women often call each other "sister", or "sistah" as they say it (the other day Sarah called to Victoria, a nurse who also helps us, by bellowing, "Sistah Vic!") Sarah and Lucy, another helper, admitted to me that when our team is here, they work at least two hours extra every day because we stay so late and they have to clean up and lock down after us. When I expressed my dismay, Lucy said seriously, "But you are helping our people, so we are helping you."

At any rate: lunch. Big vats of fried rice (very popular here), roast chicken pieces or whole baked fish complete with heads, fried plantains, and "red-red," a spicy bean dish made with black-eyed peas and bright red palm oil. One day we had yam balls and meat pastries--quite tasty. The hospital workers eat later than we do (they are on a more British system of "tea" at 11:00 and lunch at 2pm). One day they brought in something called "fou-fou", which they eat with groundnut soup. I have wanted to try this for a while, and watched in horrified fascination as it was unveiled: baseball-sized blobs of sticky paste made from cassava root and plantains pounded together in a huge mortar & pestle. I would have eaten it, too, except . . . fou-fou can only be eaten with the hands--small bits pulled off and dipped in soup. It's considered rude to eat it with a spoon or fork. After a morning of handling sweaty kids in a much-less-than-hygenic environment, I just couldn't do it.

Dinner we have at the hotel also, because we are either too tired or it is too late to go elsewhere. The floor nurses (Jan Gauger and Kathy Goedde) as well as the pediatricians (mentioned earlier in this blog) often aren't home until 9pm. The hotel serves fried rice, kebobs of chicken, beef or goat(!), some curries and some Chinese dishes. Also . . . pizza! Not bad, actually. With such a big breakfast and dinner, I (like other members of the team) often skip dinner altogether. A granola bar and bed sound much better!

My snapshot of the day is Michael Appiah, a 5-year-old with a bad tongue-tie (the tongue is overly tethered to the floor of the mouth, impeding speech) that we squeezed in as day surgery. After a series of very irritable babies, he bounced into the room and immediately began to smile. When my Child Life counterpart, Christine Melchert, tossed a ball at him, he let out a peal of laughter that was like a balm on our frazzled nerves. Even after getting his needle poke, with tears running down his face, he started to giggle again at the sight of that yellow ball.

Anesthesia


pre-op angst


Seth and his mom play with bubbles


ready

smiley


waiting


doctors in training


horseplay on the ward

It was a hectic day in pre-op today. We've had potential patients showing up all week that didn't attend screening, so we have to evaluate them, plus check in our scheduled patients, plus keep track of who everyone is--all among a patient group that speaks little English (Dr. Kofi Boahene and his sister Yvette have been a big help, though).

At the busiest part of the day--three babies screaming as their IVs were started, two families waiting to be seen, and two Komfo Anoyke adult patients (we are sharing pre-op space) in hospital gowns being wheeled through--a local TV crew showed up. Interviews took place right in the pre-op room, complete with cameras and lights. With the cameramen shouting at one another, hospital staff being interviewed, babies screaming, and everyone jostling for space, I had one of those "we're not in Minnesota anymore" moments.

By contrast, the recovery room (where I spent some time today) was wonderfully quiet. There I watched Mary Alice Seipp, Felicia Addae, and Jeanne Mach soothe and monitor patients just after surgery. A heart monitor beeped softly as Mary Alice urged little Solomon to wake up. Young Yaw, who was such a handful in pre-op, sat up dizzily in Felicia's arms as she murmured to him in Twi, the native language. Seth and Danial, two small boys who shared a recovery room bed, symbolized the success of our interactive work here with Komfo Anoyke. Danial came to our mission screening last year, but was too underweight for surgery. Dr. Donkor followed up with him and did his cleft lip surgery in December of 2004. Now we are repairing his palate. Seth's lip was done by our team last year, and this year we are able to do his palate as well, and Dr. Donkor will follow his healing process.

We spoke with Dr. Donkor today about the impact we are having here in Kumasi. He said that his fledgling cleft team is growing, but still lacks funds and personnel. Because of our resources, a team like ours can do 70-80 surgeries in a week, as many as Komfo Anoyke is able to do in a year. Plus, our presence builds awareness and sympathy, encouraging acceptance in the community at large. Every child whose cleft is fixed by CSI goes back out into the community to serve as an example of what can be done. We also talked with a oral surgical resident, Dr. Alex Acheampomg, who has been inspired to get orthodonture training to help Komfo Anoyke cleft lip patients straighten their teeth after surgery.

A final snapshot (OK, I love these bats!): walking out of the hospital with Vance and Christine as dusk was settling, and looking up at the pale indigo sky filled with crows--no, not crows! Same size, and almost the same shape. Fruit bats, flying toward dinner.

Lynn Randall, CRNA, accompanying a young patient to surgery


A palate patient in post-op


Mothers caring for their children in post-op

A young patient admires his new lip in post-op


Dr. Kofi Boahene is surrounded by staff eager to help and to learn


Joyce Sidman cheers up a nervous patient and his mother

The air here makes me appreciate our technolgy and pollution control laws in the U.S. Cars and buses billow out dark clouds of exhaust, and smoke pours into the air at all hours from small cookfires and larger piles of burning trash. Small industries like the furniture-making factory near our hotel also belch black plumes. On our ride to the hospital in the morning, smog hangs in grey layers over the houses and the hills beyond.

Yet through it all stride these magnificent Ghanaian women, gleaming like tropical birds. I love the fabrics with which their dresses are made; I have looked and looked and never seen two alike. The patterns are like nothing we have in our country, except maybe in batik. Swirls, stylized motifs, paisleys, medallions--they are always dramatic and surprising and look terrific on the stately women that wear them.

I slipped on scrubs, shoe covers, a mask and a "poof" hat, and went into the operating room today. Dr. Jim Sidman and Dr. Michael Fritz were both repairing cleft palates, which is a longer and more complex operation than a cleft lip repair. (Closing a gaping palate--the roof of the mouth--allows a child to speak properly and swallow normally. It does not change the way a child looks, but is critical to leading a normal life.) Assisting Dr. Sidman was surgical resident Dr. Samuel Ansah and nurse Comfort from Komfo Anoyke. Two Ghanaian medical students and several nursing students also looked on. The area around Dr. Fritz's table was similarly packed with Ghanaian medical staff wanting to soak up learning and trade ideas.

I planted myself next to Mr. Lynn Randall, a CSI Nurse Anesthetist, who was squeezing a large red plastic bag that looked a little like a whoopee cushion (!). He was manually "breathing" for the patient. He explained to me the monitor above his head: a green line with regular blips for heart rate, a blue line with a series of alpen peaks for respiration, and a red line with small triangular waves for oxygen levels. He showed me how, when he squeezed the bag, the blue alps peaked. In the states, he said, he's only work the bag manually for a little while, then let the machines take over. Here there are no ventilators. "How do you know how fast or slow to pump?" I asked. "Well, it depends on the age and weight of the child," he said, and mentioned a few technical measurements that meant nothing to me. "Besides," he smiled, "my hand knows what to do."

My snapshot for the day: that ring of still, intent faces, eyes focused above their blue pleated masks. The red bag whooshing softly in and out. And the OR light shining down on that small brown face, which would be healed, and whole, in a few weeks' time.

A mother and her child in post-op


Hands

Last night the main team rolled in, picked up a few team members, and drove straight to the hospital to unload and set up anesthesiology equipment for today's surgery. Later that evening, they came back for a well-earned rest and informal team meeting. It feels fabulous to be all together and working as a unit.

First surgeries today! Vance Dovenbarger, our team photographer, captured lots of nervous moms and stoic kids before surgery, and some overjoyed parents seeing their children afterwards. With their lips repaired, some of them look so different that only their big beautiful brown eyes are recognizable.

The first few hours of the work day were a flurry of babies: one minute staring wide-eyed at bubbles, the next minute crying angrily at being denied their morning milk (patients cannot eat or drink for 6 hours before surgery). Esther, a toddler after my own heart, spent a while being cranky, then stacked cups and tossed balls with me, breaking up into repeated fits of giggles. After reading all our books aloud in perfect British English, 14-yr-old Willington experienced his first jigsaw puzzle. I showed him the trick of finding the corners first, and he built a jigsaw snow leopard in no time.

Pediatricians Dr. Betty Wu and Dr. Peter Melchert were everywhere at once, checking kids before surgery, stabilizing patients in the recovery room, and starting IVs. Dr. Wu was concerned about 10-yr-old Naomi, who came in flushed and hot with a temperature too high for surgery. She was hydrated with an IV and given Tylenol to bring her fever down, but surgery was postponed until lab results came back (unfortunately a much longer process than in the U.S.!)

Several new patients also arrived needing to be screened, which added to the excitement. As I write now at 7:30pm Ghana time, most of the medical team is still at the hospital, ushering the last patients into recovery and onto the ward.

We have had thunderstorms almost every afternoon, though the dry season is supposed to begin any day now. The snapshot I'll leave you with is from yesterday evening, as we sat outside eating a late dinner in the hot, heavy air. One side of the sky showed a sliver of moon with a few stars, while the other teemed with dark clouds and splinters of lightning. And at my feet, the kohl-rimmed eyes of a stray cat stared up at me fixedly, willing me to drop a crumb of food.

Anxious families check the surgery list, hoping to see their child's name


A mother and her child wait in pre-op


Kofi Boahene from Ghana, together with Mike Fritz and Surgeon Jim Sidman


Christine Melchert in pre-op

Just back from posting the list of patients we will operate on this week. Such excitement! Such exclamations of relief! Fingers pointing to names, heads bobbing, babies catching the joy of their parents and smiling shyly from their pouch-wraps. A small congregation of our patients had gathered in the hospital lobby and were singing quiet hymns before they came upstairs--so we started the day with song again.

There were several poignant stories that emerged this morning. One mother arrived with an underweight baby, tiny Teresa Apenkrah, far too small for safe surgery. She had just lost her husband, she said in tears. Her cleft-lip baby couldn't nurse properly, and she had no money to buy formula. What could she do? Fortunately, we had brought along several cases of powdered formula. Komfo Anoyke Nurse Lucy found a new baby bottle to give the mother, and we wrote out (in pictures) how to mix milk for the baby. The mother promised to attend Dr. Donkor's Cleft Clinic to have Teresa followed until she is big and healthy enough for surgery.

Another mother arrived with no money for food for herself or her child, and no place to stay. Yaw Asare, her delightfully friendly little boy, was born both with a cleft lip and deformed arms and hands. She seemed to be at the end of her rope, exhausted and in tears. CSI and Komfo Anoyke doctors decided to admit the mother to the hospital so that she and Yaw could be fed tonight, then we would operate on his cleft lip tomorrow. Perhaps at some point in the future we can return with an orthopedic surgeon to straighten Yaw's arms.

The saddest and most frustrating case of the day was a young woman who had given birth to a baby with both cleft lip and palate the day before. She wanted to leave the hospital without the baby, saying she couldn't face her family or community with a deformed child. CSI pediatrician Peter Melchert, and nurse Comfort and surgical resident Alex from Komfo Anoyke, attempted to convince her that her child could lead a normal life if only she would feed her carefully and bring her to the Hospital Cleft Clinic. "This child is a gift to you," Dr. Melchert urged. "She is beautiful." As the confused woman walked away, several of the mothers whose babies were undergoing surgery swarmed around her, talking and gesturing, exhorting her to do the right thing by her baby. Alex shook his head afterwards. "This is one who might put a pillow over the child and smother it before even reaching home. But if anyone can convince her, it will be those other mothers."

I will leave you with a snapshot from the Kumasi open-air marketplace, which several of us visited yesterday in the midst of a downpour. As we wound our way through the warren of stalls filled with everything from brilliant red palm nuts, to huge hairy cassava roots, to piles of fish, we saw a "traditionally-built" woman making her way through the press of flesh, balancing an extra-large suitcase on top of her head. As we goggled at how heavy it must be, our guide (Dr. Kofi Boahene's sister, Yvette) said, "Oh, it's empty. She just bought it at the market and she's using it to keep the rain off her head!"