Sunday in Lima, laryngology conference

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.
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 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.
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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Friday – Traffic

Lima is a city of almost 9 million people, and it seems that not one person works near where they live. Districts that long ago were separate little communities have grown into a smoggy urban sprawl. It should take 45 minutes to get from San Isidro, where the hotel is, to Collique, where the hospital is. But…it almost never does. On Friday, we experienced the trifecta of traffic: rush hour, Friday night, and an event at the downtown soccer stadium. There were broken down cars, closed lanes for construction, and many near misses. Henry, our fearless bus driver for the second year, never gets heated or flustered and always gets us there safely. On this crazy Friday, we even had surgeons and anesthesiologists out in the street directing traffic to get the bus through. As snarled as it always is, this one day was somehow tremendously worse. I drive in New York, Boston, Phoenix, Tel Aviv, and other assorted places…but I hope to never drive in Lima.

So, in true Peruvian fashion, our 5 pm departure got us to the hotel at 7:30, meaning that Helen, Richard and I could not go to the wonderful dinner that had been planned, but had to head directly to the airport according to the native Peruvians on the team. We grabbed a quick change of clothes, separated out our bags for New York, consisting of two giant anesthesia machines and two monitors, and sadly waved goodbye as our friends, new and old, headed off for some closure to the week and well deserved R n R.

In quick summary, over 70 children had surgery, a similar number had speech therapy and parent training, and about a dozen medical students had hands-on experiences with surgery, anesthesia, recovery room and of course, speech. Approximately 500 chickens and 200 pounds of rice, 80 avocados and 400 packets of snacks were consumed. OK, I made those last figures up, but we did eat a lot of chicken.

Ciao, Peru, mis pacientes, mis estudiantes y amigos. Cuidate Henry en el bus. Nos vemos en abril.

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Wednesday – Helen’s birthday

Wednesday we continued as before…family meetings and individual therapy for the kids who were being discharged, and individual therapy for community members who were given appointments on screening day (or who wandered in).

By late Wednesday afternoon, we were ready for one of our highlights of the week, a trip to the surgical suite. The Speech Team put on scrub caps, booties and masks, and watched the surgeons do what they do so very well.

On this trip, we were able to see some different surgeries we had not seen before. Typically when you think of a cleft lip, you think of an opening running “north to south” from the nostril on down. On this trip, we saw some clefts running “east to west” from the corner of the mouth toward the cheek, a very rare occurrence. I watched Ryan Brown, MD and Shaun Desai, MD work together to repair one of these clefts. After opening up the area, they worked on finding the muscle fibers so that they could be woven together at the corner of the mouth. This child will now be able to pucker. They also worked on making sure the muscle inside the cheek was properly connected, so that this child will now be able to smile.

I have been to surgery many times, and if you are a regular reader of this blog, you know what is coming next. I cried. I cried to think of the skill required to pull off such a surgery, and the enormity of coming to Peru to give this gift for free. Throughout the week, I am usually too busy with my own responsibilities to reflect on it, but there in surgery, it always hits me. Watching surgery can be bloody and gruesome, actually…but if you look deeper, it is a beautiful, artful thing. So yeah, that was me crying at the foot of the surgical bed. You’d think the surgeons would ban me by now.

Because of the very heavy surgical schedule, (some left as late as 11 pm) and because of Helen’s birthday, the Speech Team left the hospital early, around 5:30. A recent medical graduate who is joining us this week, Arturo, gave us a lift most of the way to our hotel, and we took a taxi from there, sardine can style. We were surprised to find out it was Arturo’s birthday as well! When I asked him about birthday gifts, he told me that watching the surgery described above was all the gift he needed this year.

So we enjoyed a festive dinner and toasted Helen, our colleagues, our patients, our new friends, and our old ones. Birthdays in Peru are quite important, with much hugging and kissing, and we hope Helen (and Arturo) celebrate many more.

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Interprofessional Education

Academicians are talking about interprofessional education these days, and the benefits it brings. SLPs who work alongside other disciplines don’t need to be convinced of this; it has always been the way we prefer to work. Here on our Healing the Children missions, the rich interaction between professionals is one of the great benefits of our trip. We rarely have time for formal cross training, but the informal cross training is happening all the time, all over the hospital campus.

Yesterday, the Speech Team was waiting for the PACU (post-anesthesia care unit) to send the last child to the wards for the night, and we had a great spontaneous presentation from Jon Skirka, MD, about his research. He and his colleagues have developed a quality of life instrument for children with velopharyngeal incompetence, and have published some great data. In short, they showed that early intervention for kids who are hypernasal (for whatever reason) improves quality of life when compared to waiting. There’s much more about the development of the instrument and statistical measures used, which was extremely interesting for me, but I’ll skip that part for you, dear reader. Jon has agreed to visit my elective class on cleft palate this summer, via Skype, to talk about the clinical implications of his work. He will be a great addition to my newest course!

I also was introduced to Dr. Daniel (I forgot his last name), a general pediatric surgeon here in LIma. We had a great talk about many clinical issues, and then he mentioned the lingual frenulum. That’s the “string” running down the middle of the underside of your tongue. Here in Peru, and in many places including the United States, people think that clipping the frenulum will bring on speech and language development. This is NOT true. It is a very rare child who really needs to have the frenulum clipped. In fact, the frenulum acts as an anchor for the tongue, and clipping it often makes sound production more difficult. I braced myself…I was ready to gently educate my newest colleague about the rare instances where we should clip, and the general rule to not clip. Dr Daniel told me the parents of his patients often ask to have the child’s frenulum clipped…but he refuses! He only does it when the motion of the tongue tip is extremely restricted, and when the tip on the tongue is quite indented, so that it looks like a heart. I was so thrilled to hear this, and to be in 100% agreement with Daniel. He and I are cooking up some good plans to go to other regional hospitals, to do therapy for kids via internet…lots more good things. Daniel is an old friend of our great bicultural leader, Dr. Luis Montalvan, having attended school together a long time ago. It was totally random that they ran into each other, and now our missions have another local champion.

Interprofessional education continues when we work with our medical student friends, and when we head to the OR to see a rare surgery. Everyone is immersed in learning from morning to night. All of us are teaching and learning and solidifying knowledge across the week–a rich, satisfying stew. I wish I could put it in a bottle and sell it.

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Tuesday – Aviary and Cafe

Tuesday morning brought the first of our patients to be discharged from the wards. These kids had surgery on Monday and they were looking pretty bright-eyed and ready to get back at it. We saw all of them for speech consults before they left. We reassured the parents of kids with cleft lip only that we expect good speech and language development, gave them some tips and tricks, and kissed them good-bye. Children with repaired cleft palates were seen for developing oral airflow–they need to learn to use their new “equipment” now that they have two separate cavities (mouth and nose) where they used to have one. We train the parents to practice with kids, because they will not receive any speech therapy after leaving the hospital.

In addition to kids who had surgery, we also saw children for a variety of reasons, including genetic disorders, stuttering, language development and hypernasality. We had three and four sessions going at a time, in our crazy aviary. Some of our clients are going to come every day this week for intensive therapy, and some come from very far away and will try to see us again in the spring in Ica, Peru. A few have access to the internet and will contact me as needed for advice. Of course, everyone left with “regalitos” little gifts, and we never say good-bye in Peru without “fotitos” photos and “besitos” kisses.

We headed to the cafe for a lunch break, and bumped into the director of the hospital and the staff of the communications department. They welcomed us to join them for lunch, where we conversed in a mix of English and Spanish. The communication department works very hard to get the word out about our mission, including using the advertisements I make for TV and radio. I asked them if they were using them, and they said of course! So I was very happy to hear that confirmation. Making the first commercial was very time consuming, but editing the sound file for each mission is relatively straightforward, so it seems I’ve gotten a lot of bang for my buck with these simple ads.

This afternoon, we are planning a soccer game on the concrete field outside our aviary. The director lent us the soccer balls, but was disappointed to not have his sneakers with him today. He looked quite shocked that we wanted to kick the ball around, but after riding in the bus so much, we try to get a late day walk after the patients stop coming. This will be good for some laughs. I’ll tell you how it turns out in my next post.

We met some families today with very sad stories, truly heart breaking situations, both in the speech room and the OR. I can’t really say more and protect their privacy. But it will be good to shake it off a little by running around in the fresh air.

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Monday in the Aviary

We were back on the bus by 630 AM, with the fabulous Henry the bus driver at the wheel. Today is the first day of surgery, mostly for kids with cleft palates and other complicated cases. Lip repairs are done towards the end of the week because they are less likely to have any complications. Today we have a dozen surgeries scheduled and about 15 speech therapy sessions. The week is off to a productive start.

The first day always has glitches. The surgeons could not get certain supplies that we must purchase here and not transport from the States until well past the time they anticipated starting the first 4 cases. By midday the first surgeries were finishing up, which means we will probably be late going home tonight again. This is all part of the way it goes, we just have to roll with the punches.

After a team meeting, it was time for the Speech Team, comprised of me, Helen Buhler, program director of communication disorders at Mercy College, Lindsay Naylor, Mercy ’13, and Linda Rollert and Mary Byrd from Kaiser Permanente craniofacial team in Denver, to head to our offices for the day. But…where would that be? We were originally promised the Emergency Room Auditorium, on the second floor and well-hidden, but spacious. We considered the residents’ locker room, near to the wards where our kids would be recovering and near to our surgical Ready Room so we could be at hand to help out with any problems the team might have. We hoped to have our previous room in the Special Surgery building. This room is marked Auditorium, but has gradually turned into a storage area. Where could we go? The rehab building was booked, the pediatric lecture hall was booked…finally we ended up in the warehouse. It is filled with boxes full of …I have no idea… and Jerry cans of distilled water. Gallons and gallons of distilled water, lined up against one wall. Workmen come in and out throughout the day to get boxes, and the roof has quite a few birds’ nests. You can hear the pigeons cooing above you. We are trying to find a good name for this new speech office and we are toying with the aviary for now. Doesn’t that sound better than the Warehouse?

The aviary has been quite busy all morning, seeing clients from Yurimaguas, vary far from here. The families ride a bus for two days to come to Lima. Many of these patients are familiar to us from Ica, where the wonderful Bertha brought them for the first time. Bertha travels tirelessly, sometimes by canoe, to find the patients and bring them to us. She and I are hatching a plan for a speech trip to Yurimaguas, but it’s only in the daydream phase right now. We met with the parents as a group and then saw each child individually for therapy and parent training customized to the child’s needs. It was a jam packed morning.

After a quick lunch, a mom and baby we last saw in Ica found us outside of the surgical suite. She had been looking for us all and wanted to keep her speech appointment. I quickly took her to The Aviary for an extended session. Her beautiful little girl was doing quite well after palate surgery according to the mom…too bad the child would not say a word to me! Eventually, with all our tricks of the trade, Lindsay convinced the child to speak and play with us. We were able to confirm that her resonance sounds good (sounds coming from the mouth and not the nose) and that she is making good progress since Ica. It is always so gratifying to see that the advice we give is taken to heart and implemented by the families to great effect.

We said goodbye to this family, only to see them coming back about 20 minutes later. Another family was having trouble finding us, and the first mom guided the second mom to where we were. We see these instances of parent helping parent throughout the week. Everyone truly feels that they are in it together.

So greetings today and all this week from the Aviary. More posts to come.

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Back to Lima, Peru.

Greetings from Lima, Peru! Healing the Children Rocky Mountains, along with some of us from Healing the Children Northeast are back at Sergio Bernales Hospital in the Comas section of Peru. We will be here for a week, providing surgery for children with clefts of the lip or palate, as well as plenty of speech therapy before and after surgery.

Our team hails from the New York area, Denver, New Orleans, Tucson, St. Louis, Philadelphia, Miami, Austin, Nashville…I think that covers all the travelers. We were on the road for up to about 24 hours, hitting the sack in Lima at 3 AM on Sunday…too bad we had to be back on the bus to head to the hospital by 630 AM! Lima traffic is beyond anything seen in the United States, and you can beat some of it by making an early start. 

This trip, we screened the children on Sunday, so that the hospital was quiet and we could take over a whole hallway. Well, it wasn’t quiet once we arrived! The families who knew us from previous trips ran to see us, hug us, kiss us and show us how the kids had grown. We were so thrilled to see how well the kids were doing. As always, we had a great system for taking photos, starting charts, surgical evaluation, anesthesia, pediatrics and of course, the last hurrah, speech! As organized as we try to be, somehow it always gets pretty chaotic, but by the end of the day, about 80 children were screened and most were given appointments for surgery or speech therapy.

Can you guess that our scheduled afternoon off never materialized? We ended up going straight to our favorite restaurant, abutting the ruins, for a well-deserved dinner. You can guess that some of us were ready for our favorite Peruvian drink, Pisco Sour, after such a long couple of days.

After our wonderful meal, which included nuggets of cuy (look it up) and alpaca prepared rare, we went back to our hotel for some solid sleep. The majority of our meals this week will be buffets at the hotel and take out boxes at the hospital, so it was a special treat to take the time out to break bread together as a group, in the shadow of ancient ruins, after a hard day of work and getting to know each other. Tomorrow is another day.

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