In March of this year, CSA District 11 Director Sam Wald, M.D, and I spent a week in Gitwe, Rwanda, as part of a volunteer surgical team sponsored by Medical Missions for Children, a charitable organization headquartered in Woburn, Massachusetts. Accompanying us was Laura Downey, M.D., a superb CA-2 resident from Stanford. For Dr. Wald and me, it was a reprise of a trip we had done a year before, so we were reasonably well acquainted with the local medical landscape.
Medical Missions for Children (MMFC) is one of several charitable organizations that provide cleft lip and palate repair surgery in those parts of the world which lack the indigenous resources to do so. While they don’t pretend to solve all these countries’ health care problems, organizations like MMFC dramatically alter the lives of many people in need. Although I have participated in nearly twenty of these missions over the years, I have never seen a place with a greater need for the services of an organization like MMFC than Gitwe, Rwanda.
Rwandans have not had access to cleft repair surgery for decades, as a result of both chronic poverty and the 1994 genocide, which slaughtered many of the country’s physicians and disrupted its relations with the rest of the world. Consequently, a fairly high percentage of the patients who presented for primary cleft lip repair on our trip were adults. Many developing countries see frequent visits from volunteer teams, so patients presenting for primary repair are fairly rare; not so in Rwanda. Our patients weren’t just teenagers and young adults, either, but men and women who had lived for thirty or forty years on the margins of society because of their disfiguring deformities.
Of all the places I’ve worked in the past 27 years, Gitwe Hospital is definitely the most primitive. They don’t normally administer general anesthesia there, but rather use spinals as their only anesthetic for caesarian sections, their sole operation. The MMFC “operating room” was an oversized closet prior to the organization’s arrival a few years ago. The supply chain for things like electricity, water and oxygen is still tenuous, to say the least, with the oxygen coming from a welding supply house in Kigali, a three hour drive to the north.
On the other hand, due to the truly amazing organizational and fundraising efforts of CSA Educational Programs Division member Drew Patterson, M.D., who has spearheaded the MMFC anesthesia program in Gitwe for the past several years, Drs. Wald and Downey and I had incredible anesthesia equipment. In fact, it’s the best I’ve seen anywhere in the developing world: a modern portable anesthesia machine with a circle system and sevoflurane vaporizer, a NICO respiratory monitor, Massimo pulse oximetry and a couple of old Propaq’s for non-invasive BP measurement, oximetry and ECG. Overall, MMFC had put together great equipment in Gitwe, particularly from the perspective of this author-doctor, who has done anesthesia for cleft lip repairs in Saigon using diethyl ether and in the Mekong river delta using a only a precordial stethoscope and a finger on the pulse for monitoring, with a 22 gauge straight needle threaded up an arm vein for venous access.
Although we were administering general endotracheal anesthesia, we also performed infra-orbital and paranasal nerve blocks on all the cleft lip patients. Dr. Wald was a true maven on the blocks, having been tutored and inspired by former American Board of Anesthesiology President and fellow Gitwe Hospital alumnus, Steve Hall, M.D. at the beginning of our previous mission in 2010.
The combination of the nerve blocks and light general anesthesia provided excellent intra-operative anesthesia and superb post-operative analgesia. Most patients were awake enough within 7 or 8 minutes to look at themselves in a mirror, and fully awake in half an hour. In fact, our average PACU stay after GETA was less than 35 minutes. This is likely a result of the nerve blocks and attendant light general anesthesia, our complete lack of sedative adjuvants such as benzodiazepines, the minimal amount of narcotics at our disposal and, most importantly, the complete absence of any cultural expectation of lying around a recovery room for a couple of hours being ministered to. Although it seemed like maybe we should have kept the patients in the PACU for an hour after an endotracheal anesthetic, clinically, we couldn’t think of a good reason to do so. Frankly, we surprised ourselves.
Returning to the issue of our relatively “adult” patient population, you should understand that Dr. Wald and I had been recruited to go to Gitwe specifically because of our comfort with pediatric patients. Dr. Wald is a pediatric anesthesiologist at UCLA, and I completed a residency in pediatrics prior to my training in anesthesiology. Both of us particularly enjoy working with children, and after so much experience on missions in the developing world, I find the rhythm of an inhalation induction in a child quite familiar. Furthermore, there is just no question that in these situations, the children are often easier to work with than the adults. Sometimes, like this year, I even get to dust off my pediatrician’s hat and run a few clinics.
Due to my pediatric bias, I always tended to view the adult patients as a necessary, but not necessarily rewarding, aspect of these trips. So it’s surprising to me that, although I take great pride in our having successfully anesthetized a 3kg infant this March, it is actually one of the adult patients in Gitwe that I will most remember.
One afternoon I stopped by the PACU about 15 minutes after the conclusion of a cleft lip repair. The post op patient, a gentleman who is probably in his early forties, was sitting quietly on the gurney, his legs dangling over the side. His wife, who had obviously married him years ago despite his deformity, and who had never known him to look otherwise, sat in a simple metal chair a few feet away, staring quietly at his newly repaired upper lip. After a couple of minutes, she uttered a few apparently unemotional words in Kinyarwandan. I was curious, so I casually asked one of the nurses from Kigali, who was translating for us, what the patient’s wife had said. The nurse replied softly, “She says he looks beautiful.”