All of the team made it to the clinic at about 0800. we had the manditory meeting and reviewing of emergency scenerios. I started off the day operating with our host Dr Yogi Aeron. He showed me how to do his "silver stick" procedure on Farooq Mohd, an eight year old boy with a burn on his face. A "silver stick is a procedure where a tube graft is inserted into a tunnel under the lip- chin margin to recreate a sulcus for the lower lip. It seems like it takes a lot longer to do ane requires two operations, but if it gives better results it may be a worthwhile procedure. My next case, Pankay Joshi was a 12 year old was a contracted chin and lip scar. I did it with Anita James, Dr Yogi's scrub nurse for 20 years. Sheeza Rizwan was a 12 year old with a contracted neck scar. She was released and a full thickness skin graft placed. My final case was a little girl, Sonika Kumari, a 5 year old with a burned hand with a contracted hand scar with all four fingers in flexion. Dr Yogi Aeron helped me with that one and showed me a flap to improve the skin on the palm side. After surgery, I explored the clinic and consulted with Dr Yogi on several patients. I returned to the hotel a little early since I had nothing to do and we are only a few minutes away. we have a bus at our disposal for most of the night. Dr Kush Aeron found me at the hotel and took me to a phone store. I was told that a cable into the country somewhere had a problem and would be repaired by the 15th of Feb. Other cell services are available and would be affordable if I were to return. The per minute rate is about 25 cents to the US. Kush took me to a bike shop where I bought a single speed bike with drop handlebars. I brought a set of pedals and shoes from home but am a little apprehensive about riding when it is so dark in the morning. In the local bazaar (shopping district) Kush took me to a outdoor equipment shop that had some nice gear, limited quantities of course, but nice. We discovered that there has been too much snow to climb safely. Directly north ( a couple hundred km) of here are a few 7,000+ meter peaks. There is one in striking distance that is 7,800m (25,600 ft). After returning to the hotel with my new bike I ran into Mike Flynn, one of our anesthesiologists who informed me that there was pizza in room 108. Joe Herbert, our pediatrician and Jim Nichols, another of our anesthesiologists hosted 4 boxes of pizza for the group. We ended up having a group meeting discussing our concerns and the inadequacies of the facility where we are. The group leaders here made a conference call to Interplast to discuss the deficiencies. We decided that we would need to curtail the size of the procedures. 6 Feb 2008, Wednesday, 2nd day of surgery Thunder woke me several times through the night and continued while I woke at 0500. I am still waking at 0345 but have been able to return to sleep. It was very dark this morning due to the overcast sky and I did not feel like riding my new bike. We rounded this morning on all our patients upstairs. Everyone was doing well. My first case was a 7 year old boy named Negender Rawat who had a facial burn which left him with his eyelids open. I released his eyelid scars, placed skin grafts on his left eyelids, and a local flap for his right side. My second was a 22 year old Laxmi Devi who was burned on her right side. she could not extend her arm. I was able to release her right arm and took a skin graft from her lower abdomen and placed it in the defect. I got the arm to extend almost completely and with a little physical therapy she should regain all movement. The third operation as a 48 year old Sant Lal, a man burned when his kerosene stove flared up on him 10 years ago. Both of his hand were severely deformed, his wrists bent backwards and his fingers also in unusable position. We were able to only gain about 20 degrees more of extension on his elbow and fewer on his wrist. Our fourth case of the day was another elbow contracture on an 18 year old who was burned at 6 months of age. He also lost most of his forearm and hand on the same side. Dr Yogi assisted me on the case and had some good input into the case. We were only able to gain another 20 degrees of extension as well. All our patients were doing well this afternoon. I rounded with a few of the team in the upstairs filthy, dilapidated room as well as a similar room next door. Tonight after the cases were done the respective team leaders met with Drs Aeron to discuss the deficiencies of the facility. Went out to eat with the group to the "Prez" restaurant, an upscale downtown place 4 doors down from McDonalds. As usual I am spent at the end of the day. 7 Feb 08, Thursday, third day of surgery It seems like 0345 is my usual wake up time. I have been managing to fall back to sleep until 0500. I downloaded a few photos, emailed and finally got out to ride my new Indian "Hero" brand bike. It is a single speed with drop handlebars that cost 2500 rupies( about $68). I put an old pair of speedplay pedals on it that I had brought, clipped in and rode uphill for a couple of miles. The downhill return was a little scary. The brakes are not very good and the geometry is unstable. The scary part is that by the time I am on the return leg of my ride, more people are up and moving and there is considerably more traffic on the road. The traffic is more dangerous than any other place that I have been on the planet. First case was Anchal Kumori, a 7 year old who was burned in her groin and suffered a severe burn. We released the contractures and took full thickness skin grafts from both her inner thighs to fill in the defects. The second case was Ruby Rana, a pretty 17 year old who had a burn to her neck and lower face. Third case was Sumanti Devi, a 30 year old who was burned and had contractures of her right elbow and axilla. We did a Z plasty on her axilla and on her elbow released the scar and placed a full thickness skin graft. Fourth Case was Hema Kumari, a 22 year old with a giant hairy nevus on the right side of her face. We did a first stage serial excision of the nevus. Dr Yogi wanted to do a thin split thickness skin graft and let it contract down with time. Tim Sproule, Michelle Spring, and Yogi Aeron did a Tagliacozzi flap on a 7 year old boy with a missing nose from a facial burn. In a group meeting today we discussed our options for the upcoming weekend. It seems like we could see several areas and include a hike in the Himalayas. I went out to the shopping area this pm and then to dinner with Jim Nichols, Mike Flynn, and Michelle Spring. At dusk we observed a man with floppy, bent legs crossing a busy street. He had polio and has non-functioning legs. He moves by picking up his feet with his hands and placing them one in front of the other to ambulate. We were told that he has a job and we were observing him at work delivering some papers. He is an amazing man who has survived in an environment that is unfriendly to those with disabilities. 8 Feb 08, Friday, 4th day of surgery I went out on my bike this am and went out a couple of miles longer. A couple of our patients did not show this am. I was told that they did not know their surgery times and did not have a phone to be notified otherwise. My first case was a 13 year old girl, Manju Kargi, with a cleft palate that I helped Michelle Spring, the Interplast fellow repair. Dr Yogi Aeron also scrubbed in. Meenu Rani was the second case. She is a 35 year old who was burned on her abdomen and groin. She had burn scar contractures across the pubis creating a one inch thick band covering her genitalia. We did a couple of Z plasties and a small graft. Our third case was Seema Kaur, a 13 year old who burned her face. she has had a number of other skin grafts in the past but has a depigmented forehead and cheek area. We discussed many options and decided (with Dr Yogis persistence) to resurface the forehead with split thickness skin grafts and to place a skin expander when available. A Dr. "Jen” , a general surgeon from a town about 200 kms away at an altitude of 2,200 meters scrubbed in with us. One of our anesthesiologists had to leave early after suffering from some GI upset. The bathrooms at the clinic are not working and he needed a facility more reliable. We made plans to leave the hotel at 0930 on Saturday morning, make rounds at the hospital and head out for some R & R. Monday, 11 Feb 08 2nd week of surgery The musical tones of morning prayers at 6 am from the mosques nearby reinforced that I was in a different part of the globe. I started out helping Michelle with a cleft palate, lip revision, and bilateral lip rhinoplasty on a 12 year old boy. The second case was a 12 day old infant that had a rat eat the dorsum of her nose at 5 days after birth. The nose had mostly healed but was being pulled up by the wound contraction and had changed significantly over the week that we had been there. I helped Tim who decided to remove the scarred tissue and after seeing the size of the defect, created a midline forehead flap to cover the wound. It seemed to work out nicely. I looked over Michelle's shoulder a few times while she did a 3 month old cleft lip. She did a nice job. At the same time I helped Tim do a takedown of a sliver stick reconstruction of a lip burn scar contracture. The pt also had a release of a little finger contracture and mouth commissure release with advancement flaps. The next patient had an inch-thick keloid on his forearms and wrists. He was relatively functional but is also the son of Dr Yogi's housekeeper. We planned a skin graft after excision &/or a serial excision. We ended up doing a serial excision. The last case was a 20 year old with a little finger subluxation and burn scar contracture. I straightened the finger but it had been subluxed for so long that I had to put a K-wire in it to stabilize it. During the morning Dorothy Gaul, our chief anesthesiologist became ill and vomited. She was put in bed in the recovery room, had an IV and given antiemetics. In a few hours she was feeling better. ta After the surgeries we did 3 dressing changes. All were doing well and the grafts and flaps look good. Dr Yogi had me see 10 or 15 patients with him to evaluate for the March trip. Half of the crew went out to eat at the restaurant "My wife's Place". I stayed in to organize a talk for some of the local docs. I later went downstairs to mingle among a wedding. I sampled some of the food and took a few pictures. Tuesday, February 12, 2008 2nd week of surgery I ran a little bit this am. My bike is out by the parking area, I asked the desk to put it upstairs. While out running, I saw the man and his ox drawn cart filled with liquid animal dung heading up the street as he does every morning about this time. I ran back to the hotel, grabbed my tripod and tried to get some stable shots of him. The best angle is from the middle of the street and of course the most dangerous. What Mike Flynn noted may be true, that the feces filled and caked cart may be the safest vehicle on the road in that no one would like to run into it. Rounding this morning found all patients doing well. I started out with a case that I thought I was going to help Dr Yogi do, or rather watch him do. It was a case of collapsed face on Rajinders Parmar, a 29 year old who had an infected left maxilla after some dental work 10 years ago. Yogi had fashioned a prosthesis model out of dental acrylic. We opened a pocket in the buccal sulcus of the left side and placed a skin graft to line the pocket and packed it with Xeroform gauze to maintain shape. I hope it works. The remarkable thing was that Yogi wanted me to do the case and he just assisted. I had never seen or done anything like that before and kind of made it up as I went. I changed dressings on our patients in between operations and let a few go home. My next operation was on Mohanchard Thakjur, a 44 year old somewhat retarded man who had acid thrown on his face by some younger boys (rumored to be his sons). I did a Z-plasty of his neck to release some tethering. In between cases I went out with Kush and investigated a couple of hotels as alternatives to the one we are in now. Even though our present hotel is relatively expensive for a third world country, it is quite serviceable. We finished surgery around 4 pm, had a team meeting and got to the hotel a little before 5 pm. I had a talk scheduled for some ER docs and put one together with some help from the internet. As a team we visited the Cheshire Home, one of 300 independent homes worldwide that were established by Group Captain Leonard Cheshire after WWII. The home is a stately home/mansion on lovely grounds that are dedicated to caring for the unfortunate and for those unable to care for themselves. The people running the organization there were quite remarkable and sincere. What is equally impressive is that in a country covered in trash and feces, the inside of the house had a distinct lack of odor. Rough as most places are, the building was clean and orderly, a feat dealing with mentally handicapped people. One of the patients from last year's trip who had half of her face ripped off by a leopard attack and her leg eaten off, lives there. She had a dance number for us. What is remarkable is that she has returned to school, dances great with one leg and had an enthusiastic outlook on life. Those sort of things keep one coming back to these sometimes wretched areas. I gave my trauma lecture to the few people other than team members present, some of us went out to get something to eat, others returned to the hotel and contemplated the remarkable things we had all witnessed. Wednesday, 13 February, 08 I emailed this am and did not get out to exercise for the second day in a row. Rounds found our patients doing well. We were all greeted this morning by our patients with the usual “Namaste” and hands clasped together. All post ops are doing well. We will get some more dressing changes done today. We did 8 yesterday. My first case was Rekha Rana, a 15 year old girl with a cleft lip that had been inadequately rotated, she had a oronasal fistula, and a cleft lip nasal deformity. Michelle watched me redo the lip, repair the fistula and do an open rhinoplasty. Dr Yogi came in and made a few suggestions. Her lip turned out nice as well as her nose. M next case was Geeta Tindori, a 14 year old with a burned hand and contracted fingers. I released the fingers, rotated a few small flaps and skin grafted the rest. My third case was Rayni Kanojia who is a 27 year old with a burned and contracted neck. At our preop clinic she told us she had not had a period for three months. She tested positive on a pregnancy test. She showed up today and told us that she had an abortion so she could have her surgery. None of us made that recommendation to her. She sacrificed her baby for her surgery and I will do it for her. I am tremendously saddened by what she did to get her surgery. I did her surgery with the help of Joe Herbert, our pediatrician. I released her neck contracture and excised a large chunk of thick scarred tissue and placed a full thickness skin graft from her abdomen. I also released her contracted left little finger and placed a skin graft on it along with a couple of little flaps, a V to Y advancement flap on the left side of her lower lip and did a “silver stick” procedure on the right side of her lower lip. We finished the day early. Surgeries were done by 4:00 and we were back at the hotel by 5:00. I went down Rajpur Road toward the downtown area and did a little shooting. We ran into the man with polio who walks by picking his feet up with his hands one at a time and moving them so he can ambulate. We did not have anyone with us at that time to translate so I could not get a story from him. I do know that he makes a living by delivering papers and saw him working previously. He has motivated me to do more with what I have. This guy is my hero. Rosemary took us to “My Wife’s Place" restaurant for dinner in appreciation for the efforts of all the team members.
4 Feb 2008 Monday, clinic After a later than usual breakfast we had a team meeting in the 1st floor conference room of the hotel and headed for the hospital. The "hospital" is more of a clinic with a couple of rudimentary ORs and an upstairs with a number of beds. Some of the anesthesiologists and the two OR nurses stayed behind and set up the ORs while the rest of us proceeded up the hill another half a dozen kilometers to a 10 acre park owned by our host surgeon, Yogi Aeron. We were greeted by a several hundred people lining the small road into the park with their hands clasped together, Certainly it was a scene of reverence that I have never before experienced. It continued for a quarter of a mile. We set up our clinic area under a tree that had a peacock cage suspended above us. The bottom of the cage was covered with cardboard and newspaper so we weren't bombed. We screened over one hundred patients and consulted on a few dozen more. We broke individually for lunch on a concrete bench overlooking the whole scene. The afternoon got a little chilly as the breeze picked up. Dirt and dust also permeated everything from the hoard of people. A most amazing clinic day
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