The hospital is a 10 minute walk from our hotel. 31 patients were scheduled for surgery, all were admitted the night before to our makeshift preop ward. In our morning meeting, we learned that only 2 of our 6 surgeons were available due to emergencies. We planned on making the present surgeons time most efficient by using both tables in the room. When one patient’s operation is nearing completion, the next will be put to sleep on the adjacent table, so the surgeon will have no down time and immediately start on the next patient. By the time we had the system worked out, the local surgeons had arrived. We did use the system later in the day as some of the local surgeons had to leave. The first day of surgery is typically slow as we are learning how to use what equipment we have and the habits of one another.
The team completed surgeries on 29 patients. I did seven of those, one palate, one bilateral lip, and five unilateral lips, the last one under straight local on a teenager. She was quite stoic and didn’t make a peep (of course I used a slow injection technique to minimize discomfort).
I was a little surprised by the scrub nurse help. My first three cases (bilateral lip, unilateral lip, and cleft palate) I did completely by my self. I have never done these single handed. I didn’t know I could actually accomplish it. I did get a couple of nursing students as scrub assistants, but they had never been in an OR and had almost no idea how to help me. I did get an experienced nurse the last case of the day. He was helpful. The others were a teaching experience and I hoped they at least learned something from me. I learned that I could do these operations by myself if needed.
Sometime during the afternoon torrential rains pummeled the hospital and drummed a deafening beat on the roof. Unfortunately I did not get out to see the vision-obscuring rain for which the
We have good WiFi in the operating rooms and I check in with home between cases. My Ipad works good.
I returned to the hotel after a nearly 12 hour day, immediately stretched out on the bed to give my back a minute or two of relief. 5 hours later I woke. That is precisely what I avoid doing on these extreme time zone changes. I am now writing this at 0100, wide awake, and having had my customary 5-6 hours of sleep.
Tomorrow and subsequent days will prove more challenging in that I have 6 planned surgeries on my table, all but one are palates. I don’t recall having done 5 palates in a row before. The following day is the same.
All our patients did well overnight. One developed a hive-like rash and is being observed after benadryl. All 28 patients and their caretakers were crammed into two rooms about 10 x
There were 28 surgeries scheduled today. My table had 5 cleft palates assigned. Five palates in one day was unknown territory for me, and one in which I was more than a little concerned. All but one was relatively straight forward. My third patient was a nine year old with a previously repaired palate that had completely broken down and appeared to be wider than one would expect compared to what we normally see in a new cleft palate. The difficulty in repairing palates for the second time is that the tissues, of which there is a very limited and finite supply, is now full of scar and fibrous tissue. The scarred tissues are not pliable like an untouched palate and it is much more difficult to separate the anatomical components for repair. I did manage to get a tension-free closure on the palate and I hope it helps her speech and function.
By the time we were completing our second cleft palate, a hot pain had begun brewing in the back of my neck. Operating on cleft palates is done with the surgeon operating from the top of the patient’s head, looking down into the mouth and roof of the mouth. It is almost upside down, but the positioning allows the surgeon to use both hands.
We broke for lunch after the 3rd patient and gave my neck a half hour to recuperate. We were done with all five palates (remarkably) by and returned to the hotel a little after .
Wiggy, the area Johnson & Johnson rep invited the team to the Manila Polo Club (yes, real polo) for a dinner. The privileged environment and food was lovely as well as a throw-back to an era of the early 1900’s.
On return to the hotel, I learned that two of our palates bled and needed to be returned to the OR. I was on call last night (uneventful) but would feel obligated to go to the hospital tonight if either patient were mine. I looked at the schedule – neither patient was mine.
Watch for next set of photos... Dr Rod is quite exhausted and needs sleep before the next big batch of cleft lips tomorrow.
Starting to acclimate to the time zone. I went to bed at , took an ambien so I wouldn’t wake in the early morning hours, and had a thorough sleep until 0445. My internet card expired last night, so I will get over to the hospital and use their WiFi before surgery starts. We have another full load of cleft palates today.
This section will sound like a running blog – which it will be as I will update the surgeries during the turnover time. I often get called to see walk-in patients between cases, so my downtime on these missions during the day is minimal.
My patients for the day were:
Joland P, 2 year old cleft palate.
Richmond C, 9 year old cleft palate.
Jean A, 9 year old cleft palate.
Roland B, 18 yr old palate
Prescela M, 26 year old palate.
In most places we would not operate on patients over the age of 12 or 13 years who have an unrepaired cleft palate. However, it is the custom here to do the surgeries on patients that old.
As surgeries were wrapping up, Rejene Velazquez, a famous singer here visited the operating rooms and patient wards. She is a supporter of Op Smile’s program in the
We were invited to dinner by a local restaurant/culinary arts school that is also a supporter of Operation Smile.
On the walk to the hospital - kiosk worker had too late of a night.
First morning post op. Lip repair looks great, but patient is not thrilled to see me in white coat.
Preop patients and family members for todays surgery schedule. Patients come in the night before and stay, just like the old days back home.
Cleft palate repair, first morning after surgery. The suture hanging out of his mouth was placed through the tip of his tongue as a safety precaution. If the patient bleeds from a palate surgery (not uncommon), pulling on the tongue with the stout suture can control the airway in an otherwise fighting patient. The suture is snipped and slides out easily.
Bilateral incomplete cleft lip deformity, ready to get fixed.
Dr Rod operating on a cleft palate. No residents were on the mission. The other surgeons on the mission were quite skilled and talented. They just need more surgeons to handle the load of surgeries.
Waiting to be called for surgery.
Preop accomodations. It is airconditioned.
Post op ward, one of two. The beds are also against the wall on the right, not well seen.
First day after cleft lip repair.
Cleft palate repair, first morning. All good.
Cleft palate repair first morning after, all well.
Cleft palate repair first morning. Looks great.
First day post op after cleft palate surgery.
Repaired cleft palate first morning after surgery. All is well.
Parents giving thumbs up on first morning after cleft palate surgery.
Dr Marcelo Texiera, anesthesiologist from Rio de Janiero, Dr Mark, plastic surgeon from the Philippines, and Dr Rod.
Popular singer Ms Velasquez and Dr Rod on the post op ward.
Philippines, 4th day of surgery,
Ambien kept me asleep until just before 0500. The 10 minute walk to the hospital is a relaxing way to start the day. I arrive 40 -50 minutes before most of the team. Adam, the team pediatrician / pediatric intensivist back is there before I am. He has seen most of the patients, all are doing well. Each group of 25 – 30 surgical patients are discharged home each day, the beds re-sheeted, and readied for the next days 25-30 patients. Today we treated around 25 patients, I operated on five. Three of those were secondary complications, two fistulas (holes in the palate from previous palate surgery) and one bilateral lip repair that had notches.
The first patient, John Paul A. had a cleft palate.
Jay L followed with a cleft lip.
Shamendra & Rosel both had fistulas that we fixed.
Enalyn E., had an obvious scar on her lip that we improved.
I met with some of the team members who wanted to go out to eat. We went to an Italian restaurant in a very upscale/sterile/homogeneous shopping area on
Manila evening traffic is a nightmare. It took an hour to travel