Surgery Mercy-Style

Up at 6am. Most of the other bunks are already empty. Breakfast. Awesome as usual. Then I head to the OR, determined to find some action there. The big case of the morning is a takedown of a wrist contracture from a burn injury. Ironically its the same child that was sitting next to Nic on the band-aid boat onto the ship. In the room is the surgeon, assisted by an Army Gen Surg resident. An Army Ortho attending is watching as is another surgeon. I talk shop with the Ortho attending who apparently arrived a few days ago and has been denied permission to operate.

I wait out the case and then seek out another, hopefully less crowded room. I enter a submandibular and sublingual gland removal. In the room is a Peds surgeon from the US. assisted by a Aussie Peds surgeon. They don’t pay much attention to me being there, so I again wait out the case, not seeing much.

Lunch, then back to the OR where I introduce myself to the project SMILE team. Their organization is entirely self-sufficient. They bring their own supplies, instruments, surgeons, anesthetists, and nurses. They have a corner of the PACU to themselves, which is a 20x20 play area with kids and parents milling around. These are all pre-op patients. Each is wearing a hospital gown with tape declaring their NPO status on it. “Don’t give me anything to eat or drink after 8am”

The next case is a cleft lip repair. The surgeon is from New Zealand. He flew in this morning at the last minute to replace another surgeon who was ill. The anesthetists are from the Philippines, the nurses from Australia. Quite an unusual OR team.

A bit about cleft lips. At 6-10 weeks into a pregnancy, the face of the fetus is formed. The last step is when the eyes and nose come down from the top of the head to meet the mouth and also pull together to meet in the middle. It’s kind of like the motion you would make if you came up behind someone and reached around with 2 hands to cover their eyes. About 1 in 1000 times something goes wrong and the continental plates don’t meet. 1 in 500 if you’re Asian. From there nature does its best to fill in holes or defects with scar tissue.

The final product can be slight (a minor scar on the upper lip extending towards the nostril) or more severe (the roof of the mouth does not close in the middle and communicates freely with the nasal cavity). The severe cases cannot breastfeed (try sucking on a bottle with a hole between your nose and mouth). Minor ones have cosmetic defects. Nearly all will have a corresponding defect with their speech, let alone the social implications of their deformity.

Ok so how do you “fix” a cleft lip (the more minor case)? The basic idea of the procedure is to excise a wedge of tissue where the defect is. It’s like cutting a piece of pie that extends from where your gums meet your cheek above your front teeth, out over the lip, and up to just inside the nostril. Then you line up the two halves and stitch them back together. Of course there are lots of plastic surgery techniques (C-cuts, and Z-cuts, and Mallard incisions) to help make the final product look pretty. The surgeon informs me that when you reconnect the two sides that if you get the border between the skin and lip (vermillion border for you medical types) if you are off by just 1mm the result will be noticeable by an average human observer at 3 feet, which is about conversational distance. Getting the 3 points that constitute the “Cupid’s bow” on the upper lip are also important.

This is the first time I’ve ever seen a plastics case. The result is nothing short of amazing. A terribly deformed face turned into a totally normal one. This patient will be checked at the end of the day, stay another night on the ship, and then be sent home. Their sutures will dissolve over the next week, and they can start eating as soon as their post-anesthesia nausea clears.

In the US or Australia cleft lips are repaired by 6 months. Palates are done by 1 year. Later at about ten years of age, a bone graft is sometimes then put in the palate if nature didn’t do a satisfactory job catching up its growth. All cases get intensive speech therapy.

Our patients today range in age from 7 months to 14 years old. For speech therapy they will receive some teaching during their stay aboard the boat and a handout giving them exercises to do at home.

More cases follow. All the exact same defect with the exact same repair until the very last one. The patient is 13 years old, and she bravely gets on the table in the OR as she is put to sleep. Her defect is still on the lip only, but there is a great deal of scar tissue in the area. The surgeon’s best guess is that she had some manner of repair done, but there was a complication such as a post-op infection. The same sort of wedge excision followed by reapproximating the two edges is done, but the result while a major improvement is less than perfect. If this was the US, the patient would be allowed to heal and her swelling to subside. She would then be brought back for one or more subsequent surgeries to improve the cosmetic result. There will be no such follow-up for this patient.

I catch the tail end of dinner, then on to the gym and the nightly briefing. The highlight of the briefing is a case presentation. The patient is a 30-something woman who had both of her distal forearm bones broken in a car accident years ago. She adamantly refused amputation. The bones never healed back together so she has been carrying around a hand held attached to her arm by soft tissue only. The fingers only move when she holds the hand out at length.

In the US she would get multiple surgeries by orthopedists and plastics to reapproximate the bones and make them heal together, all the while making sure to recreate the correct tissue planes for the nerves, tendons, and blood vessels of her wrist. Here she received a specialized brace crafted after several days of trial and error by the physical therapy department.

The woman is brought up in front of the whole room of people. She tells her story. She is genuinely thankful and very happy with the treatment she has received. This segment of the briefing concludes with a happy Birthday (her birthday was yesterday) sung by the whole audience.

I know this presentation was put on the briefing schedule as a feel-good morale booster for the audience. I’m a skeptic at heart. It didn’t make me feel good. I wondered why she has to walk around her whole life with her hand suspended by skin and muscle waving from the end of her forearm when we have this boat here with the manpower and the tools to give a better result. I know the answer. I know why they didn’t do those operations for her on this mission. It’s too risky. The procedure would have to be done in multiple stages. She would need very close follow-up for many months. We are leaving in 8 days. I am frustrated. At this ship. At this mission. For this woman.

Then I think to myself, that there is always a line like this that needs to be drawn. Even if the boat were to stay here for a month, or a year, or 5 years there would always have to be those cases where you had to look a patient in the eye and say, I’m sorry that’s the best we can do.

Maybe that’s just the nature of healthcare. You can’t “cure” every ailment, and you can’t prolong life indefinitely. In med school we are trained how to break bad news to a patient. “Mrs. Smith I’m afraid I have some disappointing news to tell you. Your cancer has progressed. The last round of chemo did not work. We have exhausted all the options. We have no further medical treatments to offer you. I’m sorry.” But its one thing to tell an actor or talk about it in a class in med school, its another thing to say it to someone with no other hope.

~Pete