It is my duty and pleasure, Madam.

As a group, we have worked in many hospitals, in many countries.  We always receive a warm welcome, but sometimes there are underlying struggles to deal with the minutia of the locale.  A hospital administrator might insist on last minute hoops to jump through, or local staff might be promised to be available but they actually are not…lots of hurdles to face, problems to address, knock ’em down one by one and go forward.

Not at Sancheti Hospital.  From the elevator operator to Drs. Sancheti (senior and junior), everyone was ready, willing and able to make it work for the sake of the children.  The residents, the nurses, the guy who brings the tea…we were treated with the utmost care.  I could get used to that!  I think we all could!

When saying goodbye to a volunteer from the BJS, I thanked him for all his hard work.  He replied, “It is my duty and pleasure to serve you, Madam.” Well!  Who can argue with that!  The BJS is doing wonderful work, especially with orphans of farmer suicides and empowerment of girls.  I’m honored that they were on board for this mission and hope to work with them going forward.  Some of the orphans need speech therapy…we will see where life takes us…”Shari Doctor” and “Helen Doctor” have a lot to think about.

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Delhi Belly

It can sneak up on you, like a cobra.  Pounce on you, like a tiger. Smash you flat, like an elephant’s foot.  It’s the South Asian cousin of Montezuma’s Revenge…Delhi Belly.

Was it the green sauce at lunch?  Did you forget, and brush your teeth with sink water?  Was there a raw tomato with skin chopped into that dish you enjoyed? One way or another, Stranger-in-town E. coli is having a Bollywood brawl with New York E. coli.  And you’re the arena.

Some of us try to be careful:  no ice, no salad, no unpeeled fruit, no this, no that.  Some dive in and eat everything.  Do the careful ones get sick the most, or does it just seem that way?  Last year in Peru, about 3/4 of the team was sick at once…I guess that is the Quechua Curse?

The good news is, we know what to do:  The HTCNE/Fenner treatment plan.  Swallow 1000 mg of Azithromycin.  Take a Zofran anti-nausea tab so you don’t throw up the antibiotics.  Lie still.  Wait.  Eat plain, biscuits and rice, for a few days.  If you are really sick, you might even get an IV if it’s a surgical day.

Note to self:  keep the Azithromycin in your purse, not your hotel room.  You might not see your hotel room until hours after you feel the cobra coil to strike.  Those hours will long and unpleasant.

Oh the splendor and glamour of international travel!  If only we could ban intestinal hitchhikers.  Somehow they sneak in no matter where we go.

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Speech office, 9 & 10 January 2016

Today in Speech Office, 13, we had an extra special surprise.  Ryann Akolkar, our former student, spent the day with us!  She was in Pune visiting her in-laws and it just worked out perfectly that she could come translate for us. She is likely the only Kentucky native who speaks such good Hindi and Marathi.  Ryann studied at Mercy College for her pre-requisite courses, and is now enrolled in a Masters/PhD program at University of Texas at Austin.

Speech office was busy.  We had clients with stuttering and other fluency disorders, intellectual disability, etc.  Then, as always, we worked with our post-surgical clients.  As they adjust to life with a palate, which creates two cavities (nose and mouth) where one used to be, they need to learn to speak through their mouths.  We train the parents as well as the children, so that they can continue therapy at home. Most patients will have no opportunity for more therapy after we leave.  We made referrals to the School of Audiology and Speech Pathology for the ones who live in town; perhaps a few will follow up there. The place is wonderful (more on our visit there later).

For the children who had difficulty eating, we gave feeding advice and supplies as needed.  One baby was very thin, terrifyingly thin.  By the next day he was eating via syringe, as shown by the PACU team, in preparation for transition to a squeeze bottle. He already looked more alert, gazing intently into visitors’ faces, moving more purposefully, bright-eyed.  What a great success for this baby and family…something as simple as a syringe…

For babies who had a lip repair, we try to impress on the families how important it is to return next year for the palate if it is open.  Parents sometimes feel that as long as it does not show, the palate is not important.  But for speech, swallowing and nasal/otic health, the palate should be repaired.  Speech can never be properly resonated unless the palate is repaired.  We hope we transmitted that message to the parents we met in Pune.

The suitcases are all packed.  We will round on the patients one more time in the morning and head out for some RnR in Goa.  We can all be proud of a job well done.

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Meet the Team:  Glenn Casteneda, MD

Glenn is a pediatric neurologist, based in Westchester, NY.  Well, he is based there, but travels on medical missions for up to three months a year.  On our cleft palate/lip surgical trips, Glenn mostly works in the PACU, the post-anesthesia care unit, keeping a sharp eye on the kids as they wake up and begin to breathe with their new “equipment.”

Glenn is a fun one.  He works hard all day, and somehow comes alive after dinner, ready to celebrate the occasion..any occasion!  He is our favorite storyteller.  You can ask him about the time he was in the Phillipine military academy, the time he crossed from one island to another in a sketchy canoe, the time he got that scar…well, it’s better if he tells you himself.  Buy him a drink and get ready to laugh.

Recently Glenn told me a new story about his trip to Sierra Leone.  He was working in the Ebola unit, wearing those big space suits for two hours at a time.  He told me about the patients who lived, and the patients who died.  Is he brave or crazy? Yep, that’s Glenn.  I hope to travel with him many times more, generating more stories as we go.

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Speech Office, 8 Jan 2016

Speech Office, 8 Jan 2016
We were given a lovely office in the outpatient clinic to use for our speech office…with any luck, we will have it all week. Helen stayed back at the hotel today, a bit under the weather, so I soldiered on by myself. A local employee worked as my translator. 
It’s always a surprise on these trips…we give appointments, but sometimes the patients show up at different days or times than expected, sometimes they show up without any appointment, and sometimes we wait for those who never return. In light of this, every day is a great adventure in speech therapy.
My first patient was a young child with Down syndrome. He was a bit suspicious of the white coat, but he did enjoy Helen’s wind up chattering teeth. The parents were hoping for a secret bullet to help the child in his speech and language development, but, alas there is none. I gave him a rough hearing screening, explained about the expected language development for kids with Down syndrome, and offered very specific strategies for helping the child to master more vocabulary. Kids with DS need to have a large vocabulary before they start to combine two words into a little sentence, so building up the vocabulary is job one. I tested the parents’ learning by having them repeat back to me what I had said. Because they live in a small town, there is no school he can attend, so it is all the more important for the parents to work with the child on speech and language development. Mom’s resolve looked strong, as did Dad’s, so I have high hopes for this young client.
The next 4 patients were typical of who we see on these trips. All 4 had hypernasality associated with cleft palate. Sometimes, even though the palate has been repaired, the valve action of the palate and the walls of the upper throat are not sufficient to block off the nose and force the sounds out through the mouth. Sometimes there are additional surgical procedures that can be done to help this valuing action. Sometimes speech therapy can help. It depends on the structure and function for each individual patient. These patients had been seen on screening day and found to be stimulable for better oral resonance, and so were coming for therapy. 
Overall, it was a good day in the speech office, Room 13. Dinner was in the hotel, at the buffet, so it was an easy night for everyone to grab dinner when they got back…some of the surgeons and nurses returned quite late. Thankfully, Helen was feeling better and able to enjoy a light dinner. 
Tomorrow is another day.

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Greetings from Pune, India

 

Greetings from Pune, India!

Did I surprise you there? Were you expecting Peru? Healing the Children Northeast has a set of wonderful new opportunities to expand cleft lip and palate services across the Indian subcontinent. We are following in the footsteps of Dr. Dicksheet, led by his daughter, Supira Dixit. You can see an hour long film about his life by googling Flying on One Engine.

Where’s Pune? Well, it’s far away from New York, that is for sure. The time difference is almost opposite (10.5 hours) so the jet lag is bad in both directions. We flew to Dubai (about 12 hours) waited in the airport about 5 hours, took a flight to Mumbai for about 3 hours, and then a 4 hour bus ride…which took almost 6 hours. So yeah, it’s far.

Our team will be a total of 26 from Healing the Children, plus Dr. Larry Weinstein from New Jersey and 3 students. Dr. Weinstein has worked here at Sancheti Hospital for many years alongside Dr. Dicksheet, performing plastic surgery.

After about 3 hours of sleep laying down in an actual bed (oh heaven), we headed to the hospital for Screening Day. The chaos was minimal due to many years of previous plastic surgery “camps” as they call them here. Helen Buhler and I screened only the patients who were coming for cleft palate, cleft lip or other speech and hearing disorders, so we saw only a small fraction of the over 700 patients who passed through the screening process on Thursday. Thanks to Supria notifying the medical community that there would be speech therapy available on this trip, plus a good shot of serendipity, we were joined by two SLP students and a professor from The School of Audiology and Speech Language Pathology here in Pune. The students tirelessly translated and helped with patients all day. At the end, we were thanking them and they were thanking us, the mark of a good day and of a true exchange of ideas. We are invited to give an informal talk at the college on Monday, and they will be joining us here to see patients on Sunday as well!

By late afternoon, surgery was well under way for patients who needed only local anesthesia; in fact, the surgeons and nurses returned to the hotel quite late, to eat a delicious Indian dinner on the roof. The weather has been in the 80’s during the day, and in the 60’s at night, so the roof was a great place to relax and unwind before a proper night’s sleep at last.

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Sunday in Lima, laryngology conference

Sunday
I am in Lima, Peru again…but this time, I am on a laryngology mission.  I’m the SLP on the team, consisting of Dr. Craig Zalvan (of Phelps Hospital and, as of this semester, an adjunct faculty member of Mercy College’s program in Communication Disorders), Dr. Craig Berzofsky (yes, two Craigs, double trouble), Aaron Forbes, nurse anesthetist, Dr. Pat Chery, anesthesiologist and Lima native and OR nurse Marcella Steger.
Somehow, when you fly to Lima and home again, it is red eye both ways.  So, we arrived quite bleary-eyed on Sunday to Hotel Runcu in Miraflores.  I was able to have lunch with Maria Teresa from Kusi Rostros, one of our partners in caring for kids with clefts…more about her later in the week, but can you imagine that I spoke Spanish for 2.5 hours on topics ranging from family life to surgery to surfing! It’s a good thing MT has patience.
We had a great dinner, with pisco sours of course, and went to bed early.  Tomorrow is a  big day.
Monday
We were in our taxis by 7:30 am, off to Hospital Rebagliati, a giant white and blue edifice.  I don’t know how long it would take to figure out how to get around in this place…a resident confided that after two years, she still gets turned around.  Dr. Centennial met us at the gates.  It was wonderful to finally put a face to the name.  He has been working behind the scenes with CZ, Luis Montalvan and our medical student friend, Lily, for about a year to pull this conference off.
We jumped right in, seeing an assortment of people with lesions in the larynx.  The larynx, or voice box, is actually quite a small piece of anatomy, but it is where the vocal folds live.  These two little shelves of tissue, looking like pearly, grey bands in health, can be affected by many different insults and injuries.  Think about how much your voice is who you are…when you are hoarse for a few days with a cold or a sore throat, think how jarring it is to hear yourself.  In those cases, it’s pretty funny, because it passes in a few days.  The patients we were seeing have vocal pathologies of longstanding duration, one in particular for 8 years.  So the goal of improving the voice through surgery is a lofty one.  However, the larynx is just a valve at the top of your lungs, and a narrow place at that.  (Think of a whoopee cushion.)  So while we value the voice and work hard to restore it through medicine, surgery and therapy, keeping the airway open is the primary concern.  Some lesions we saw were in danger of keeping the patient from breathing.  When breathing and speaking are in competition, breathing must be giving priority; however, the microsurgical techniques being taught this week can often give a good result for both.
In the clinic, the young ENT residents ably passed the fiberoptic endoscope through the patients’ noses, and around the bend to see down the throat (We have this equipment at Mercy College, too.)  Dr. Zalvan, always teaching, gave some pop quizzes to the residents as we went. Without revealing too much personal information about the patients, we saw some cysts (like a ball under the thin mucosal layer of the vocal fold), some vocal fold paralysis, some old scars from previous injuries, and papillomatosis.  Papilloma are wart-like growths that grow anywhere in the throat and spread…and spread, and spread and spread.  They are caused by an HPV virus, similar to genital warts.  Almost all of us are exposed to these HPV viruses over time, but not everyone gets the warts.  It’s not clear why some people fight it off and some people get lesions.  We saw many cases of papillomatosis, one so severe that breathing was compromised.  That patient may end up with a breathing tube in the neck before too long.  The vaccine Guardasil protects against these strains of HPV. Dr. Zalvan predicts that if we get youngsters vaccinated, we will be done with this disease in 25-30 years. Because the papilloma spread and recur, patients have many surgeries and often end up with scarred vocal folds. Laser surgery, as is being taught this week, is much more sparing of the vocal fold itself, while effectively removing the lesions.
We saw many patients and started to put together a schedule for surgery on Wednesday and Thursday.  After yet another wonderful meal, and a quick drink at our hotel rooftop bar, we headed to bed…or to the casino.  It was bed for me.  Tomorrow is a big day. 
Tuesday
Tuesday was the beginning of our conference, an all day program of talks and roundtables.  As with many of our Peruvian adventures, we hoped for the best, planned for the worst and rolled with the punches.  Well, we were all pleasantly surprised when 90 people showed up to attend!  Advanced registration was very low but everyone just showed up and paid at the door.  So far, so good!  We also had a simultaneous translation system, where everyone had headsets and the translators sat in a broadcast booth.  As we spoke in English, it was immediately translated into Spanish, and vice versa.  Just pop the headphones on and off as need be.  It was just like the UN!  Did I ever tell you I wanted to be a translator at the UN when I was a child?  So, we were able to present in English and it was impeccably translated with no time delay. Perfect!  The roundtables were thought provoking, with interesting questions and the conference talks, by our team and by local physicians and SLPs, were amazing–educational, well-paced and on varied topics.  I cannot express how great the day went, in no small part to the hard work of Dr. Centero, Dr. Luis Montalvan and of course Dr. Craig Zalvan. I was able to connect with some local SLPs who have an interest in voice. Who can say what great collaboration that will lead to in the future?
With ENT, head and neck, med students, residents, nurses, anesthesiologists, SLPs and perhaps a few others, this conference was interprofessional education at its finest. Tomorrow we will all be in surgery together, embarking on more adventures.
Wednesday 
Today the conference continues with surgery.  We will have one operating room, with a closed circuit TV link to a conference room down the hall.  There will be two way communication as well, and the surgeons will be able to spend time between cases with the attendees.
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