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July 1, 2010

No excuses: making time to make changes

Angeline Lim, MD

Angeline Lim, MD

I AM OFTEN ASKED HOW I FOUND TIME TO ATTEND A recent mission trip in China to repair cleft lips and palates. I have to explain that some of my favorite moments in plastic surgery have been on these missions. There is already such breadth and depth to plastic surgery, but these trips have added sparkle to those dimensions.

I was asked to be a part of this trip to Changde, China by LocumTenens.com, and having had such incredible cleft surgery experiences in Guatemala and Mexico, I jumped at the opportunity. We’d be spending two weeks at a hospital in Hunan province with a team of almost 40 American medical providers and about 20 local Chinese staff.

Spearheaded by the generous folks at the Chinese Agape Foundation, the focus of this medical mission trip to Changde was purely cleft lips and palates. Additional support came from the Jackson Family Foundation, the CARIS Foundation, and SmileTrain.

First Day: San Francisco to Tokyo, to Shanghai, to Changde

Let’s start at the beginning, which we’ll call Day One (really, it was two days, but all that traveling fuses into one in my mind). I had almost 20 hours total of flight time, not counting stopovers. Once a non-believer, I really appreciated my TED hose on this journey.

I finally arrived at the hotel in Shanghai around midnight with my woefully inadequate Mandarin, had a quick night’s sleep, then it was off to the breakfast buffet. I started out strong, with not one - but two - breakfasts that first day.

After breakfast, the team met for the first time in the hotel lobby, and it was time to get on a series of buses - one to take us from the hotel to the Pudong airport, and another to take us from Pudong to Hongqiao, where we would finally figure out how to get our boarding passes for the flight to Changde.

The amount of luggage we had collectively was staggering, to be fair almost half of it was donated medical supplies. We were finally claimed at the Changde Airport, a humble little spot that reminded me a bit of the old airport in my hometown in Ohio. Tiny, simple, and intimate.

First, we met Ron Brown, the director of the Chinese Agape Foundation, who helped us settle in at our hotel, which would become our home in Changde for the next week and a half.

Next it was off to the hospital for a lovingly cooked meal. The staff was extremely concerned about we Americans getting enough to eat. They prepared an entire feast of "Westerner-friendly" dishes for dinner. Forks and spoons, nary a chopstick in sight that night, and then, inexplicably, there was the fishball soup.

We then had an official meeting at the hospital, where we met many key people, including the local hospital officials.

They got my last name right, and since I hadn’t given anyone my Chinese name, they made a great attempt at translating "Angeline" into Chinese characters.

It was rather late when we were finally given a tour of the hospital and operating room, and we got to meet some of the tiny patients we’d be working on the next day. The parents were excited to see us; the babies, less impressed.

In China, Day Two

A six-month-old little boy, ready for the day of surgery ahead of him.

A six-month-old little boy, ready for the day of surgery ahead of him.

Our first official day of work in Changde, but before we could start, a very official opening ceremony, held on the basketball courts outside the hospital. The American portion of the audience roasted patiently in our seats in the oppressive heat and humidity. The entire time in China, I never saw any of the locals break a sweat. Amazing.

My first patient was a six-month-old boy with an incomplete cleft lip. The hospital itself was pretty well equipped and run. Unlike the previous medical mission trips I had been on, where we were MacGyvering it in desperately rural parts of the country, this hospital in Changde was essentially like a typical community hospital at home.

My second patient of the trip was another six-month-old charmer, this time with a complete unilateral cleft lip. He was a remarkably peaceful baby. I think he had learned to work his cleft to the max - he enjoyed stuffing almost his entire hand into his mouth for comfort. So cute.

After dining at the "westernized food" section of the hospital, we finally caught on and joined the regular hospital staff for their meal service. A little spicier, and oh, so good. I’ve eaten in a lot of hospitals
over the years. Hands down, the grub we got in Changde was the best hospital food ever.

In China, Day Three

My first and only patient of the day was a very handsome 18-month-old boy with a fairly typical cleft palate. In case you aren’t familiar with clefts, imagine yourself looking up into the roof of a child’s mouth. You can see the two pendant shaped things hanging on either side of the middle gap; those are the uvula - that funny thing that you see in the back of your throat when you say, "aah." Clearly, those are supposed to be one structure in the midline, just like the soft and hard palates, extending forward to the back of the teeth.

Now imagine yourself doing surgery to fix it. You’re almost working upside down and backwards to fix some smallish structures in a small, deep, dark hole. You do have a little help from a device called the Dingman retractor, which resembles a torture device. Its metal attachments help keep the tongue and cheeks away from the area of interest.

The giant hole in the middle closes by bringing the tissues from the sides together. The gaps on the sides quickly fill in with tissue in the days after surgery. When the cleft palate is repaired, the babies are able to drink and eat without liquids or food regurgitating out of their noses. The most important part of this operation is bringing the muscle of the palate back together. A good muscle repair - in a child who hasn’t started vocalizing yet - can eliminate many of the speech stigmata associated with clefts.

The next day, pictured with Lim and his mother, who was very happy to see her little boy’s lip repaired.

The next day, pictured with Lim and his mother, who was very happy to see her little boy’s lip repaired.

After palate surgery, the patients are usually a little miserable and pretty thirsty and hungry. The most amazing thing about the whole process is how quickly the babies bounce back after surgery.

One of the most peculiar hospital customs that the medical team had to adjust to was the wardrobe ritual. A lot of us who work in the OR become a little particular about our garb. Myself, I often hoard and launder my own sets of scrubs (as another surgical resident confessed to me once, "The hospital-washed scrubs are just not as soft."), and my OR shoes of choice are clogs that I’ve broken in over the span of my entire career. You get attached.

So we had all brought our own scrub tops, pants, and shoes, but the lady standing guard at the front desk to the ORs stopped us soundly. We finally figured out that we were supposed to change into their green scrubs, wear their disposable hats, and change into flip-flops.

The flip-flops turned out to be non-negotiable, but we Americans slowly pushed to have our way with the scrubs and caps.

I tried to learn the Chinese names for my most frequently requested instruments: mie tze (pickups), dao (knife), jien dao (scissors). How do you ask for "6-O fast absorbing gut on a small needle driver, please," in Mandarin? I often resorted to pointing and grabbing.

In China, Day Four

Morning rounds on the first floor. At the First People’s Hospital of Changde, there is no recovery room. Admittedly, this wasn’t what any of us were used to, and following this Changde custom would
slow down our surgical day’s progress considerably. Besides, our team included some talented nurses who were itching to get to work.

We were able to commandeer an empty OR and transform it into our Post Anesthesia Care Unit. Hats off to our recovery nurses and all the caretakers for working their magic.

In China, Day Nine

Laundry day at the hospital. Actually, every day was laundry day - each morning you could see a different assortment of clothes hanging outside windows and on railings. With the degree of humidity in
Changde, I’m surprised anything was able to dry.

In China, Day Eleven

Lim’s final patient on the mission, a seven-year-old boy, photographed with his parents in Tibet.

Lim’s final patient on the mission, a seven-year-old boy, photographed with his parents in Tibet.

My last patient of the mission, a seven-year-old boy, was perhaps the most remarkable of the trip.

My new friend, William Zhao, whose kindness and dedication will become evident shortly, told this incredible story to me.

Word of the Chinese Agape mission in Changde had somehow made it to this boy’s family, which is from Tibet. With a lot of help and planning the little boy and his father made the 14-day trek - mostly on foot, but also via donkey, bus, and train - from their village in the mountains of Tibet to our hospital in Changde. William, who lives in an entirely different city in China far from Tibet, was instrumental as guide, translator, and friend.

I was only allowed to repair his bilateral cleft lip. Despite the team’s pleas, the hospital would not allow us to perform the repair of his palate as well.

Lim, with new friend William Zhao and the patient’s father at the little boy’s bedside.

Lim, with new friend William Zhao and the patient’s father at the little boy’s bedside.

Last Days in China: Changde, to Changsha, to Shanghai, to Home

Friday was the team’s last day in Changde. A few people had already left earlier in the week, so our numbers were sadly dwindling as our memorable trip to China drew to a close. After morning rounds on the handful of our remaining patients, we took one last opportunity to thank the local staff for their kindness, patience, and fantastic care.

There were a lot of tearful goodbyes as we tried to board the bus, and promises were made to see each other again at next year’s trip.

Another bus then spirited us away - this time a nearly three-hour journey to the city of Changsha - from where most of us would fly to Shanghai, spend one night, and then find our separate ways home.

The Shanghai crew finally settled in at the hotel late, around 9 pm, but we were determined to see at least a glimpse of the city. We only had about six hours in Shanghai, but we made the most of it before heading back to the airport and finally returning home.

This mission trip to China was such a rewarding experience - not just seeing a tiny slice of this giant nation firsthand, but being able to give back a little something of myself, too. I am thankful for  everyone behind the scenes, the amazing foundations that helped us get to Changde, and the generous locals who helped us. It was a privilege to be part of the American team, every single one of whom rallied to make it happen for the children.

Some of you might wonder, "How is there time for me to spend two weeks in China?"

I am tempted to respond, "How is there not time?"

This article contains excerpts from Dr. Lim’s blog, My Plastics Life, myplasticslife.blogspot.com. Special thanks to contributing editor Tara Freiberger of LocumTenens.com.



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