This will be my last post from Karaikal. The final days of clinic, packing, saying goodbye, and travel are hectic and chaotic to say the least. Again, our hosts, the Rotary Club of Karaikal and the Vinayaka Medical College treated us to farewell ceremonies and gatherings all under the growing thunderstorms that marked the beginning of the monsoon season. The lightening over Karaikal provided a live fireworks show for our last social gathering exchanging goodbyes, gifts, and business cards.
It’s amazing how fast the time goes. The 2012 Karaikal team did what we were supposed to do, fixing smiles and changing lives. The difference is truly dramatic! In some cases, it’s difficult to tell that it is the same child when comparing the before and after photos. Over the past ten days or so, the team performed 67 surgeries and more than 116 procedures, of which 60 percent were burn restorations and 40 percent were cleft palates and lips. We evaluated over 160 patients through the clinic and did dental extractions and built orthodontic devices to assist cleft palate patients.
The dynamic 2012 Karaikal Rotaplast team
Rathi smiles as she says goodbye to the team after the doctors changed her burn dressing on the final clinic day.
Dr. Brad changes a dressing and passes along care instructions on the final clinic day in Karaikal.
As we prepare to leave Karaikal I want to say a personal thank you to our hosts, The Rotary Club of Karaikal, and to the many members of their families, hospital staff, and volunteers that made this service to the children of Karaikal possible.
The first time I really get to visit with people is in pre-op. It’s a time when parents are nervous, kids are scared, restless, and hungry, and there’s a general drive to get patients double checked and the first batch into the operating room. Sometimes, at that moment, someone in the crowd catches your eye. Sinthuja caught my eye.
Sinthuja is an adorable little eight year-old whose eyes tell you up front that she trusts you. She’s quiet yet expressive with her hands and her expressions. Her mother tells me that Sinthuja really hasn’t been able to speak due to the cleft palate and lip. She’s a high performing third grader who loves school but has difficulties communicating with her teachers and fellow students. Her family and close neighbors can understand her but communicating is very difficult for a shy little girl.
Her family heard about the Rotaplast mission from a local Rotary club and traveled the 100 km and five hour trip to be here. Travel here in southern India is slow at best.
I caught up to the family while in the recovery ward and I asked what the Rotaplast mission means to the family and Sinthuja.
For starters, she’s hoping to be able to speak better. At this point, Sinthuja beckoned me to lean down so she could whisper to me. The voice was soft and a bit nasal as cleft repairs tend to be but I was clearly able to distinguish her words. I don’t speak Tamil but the sounds of words were clear. Her mom says that the surgery was an immediate improvement and they couldn’t be happier. I asked if she would be getting speech therapy and her mom proudly declared that, as a mother, she would be the speech therapist.
It was at this point that the conversation took a turn I hadn’t expected. Her mom asked me what I thought the causes of cleft palates were. I talked about how there’s a genetic component as well as a link to a lack of folic acid. She thought that the folic acid link wasn’t as key as environmental causes. Sinjutha was conceived in the first month after the tsunami of 2004. Sinthuja’s mom knew of three other women who conceived during that time frame and all of them had given birth to children with significant birth defects. She wanted to know if we were looking at clusters of cleft lips/palates that some of the towns experienced and the environmental factors post-tsunami.
As a matter of fact, we have one team member that is exploring that very question.
Dr Namrata Upadhyay, our team dentist, has been collecting DNA samples to explore the causes of cleft lips in the Indian population. Research has suggested that in the Indian population folic acid deficiency may not be the only key variable so she is collecting DNA samples from our cleft patients as well as DNA samples from a control group of other hospital patients. Additionally, she’s exploring the methods of DNA collection and making an evaluation of which method provides the greatest DNA sample by the least invasive means. Other members of the genetics team from Pacific University, San Francisco are exploring the geographic clusters and the soil, air, and water, looking for environmental variables.
The idea is to isolate the environmental or other components that are specific to this population in order to reduce the incidence rate of cleft palates and lips.
Little Sangeetha came to us one afternoon during a walk in clinic. Sangeetha fit all the criteria for a priority case; cleft lip, less than six years old. By getting the surgery done this young, she’ll get the maximum benefit as she starts her speech development. In every way, she represents the patients we are trying to reach.
After clearing the intake clinic, she and her mom spent the night at the hospital. Scheduled to be the first patient of the day, misunderstandings about not feeding after midnight pushed back her surgery time. She’d had some formula which could cause problems during the procedure.
Finally the time arrived for Sangeetha’s mother to entrust her baby to our care. She was quite understandably nervous and concerned for the welfare of her baby. From the time the baby leaves for surgery until she’s reunited with mom two hours or more can pass. Two hours can seem like a lifetime.
Patient transporters Mary, Allen, and the OR nurse bring Sangeetha up the long hallway to the operating room.
Dr. Soma performing surgery; tiny patients require a fine touch. Sangeetha’s surgery is a relatively simple cleft lip repair but will have life transforming implications.
During morning rounds Sangeetha is looking bright and happy for Dr. Amie Shaw
Karaikal is rich in history and tradition. Local Rotarian K. Raghavasamy invited me to his home to learn about the history of Karaikal and the work that’s been done by Rotaplast over the past eight years.
Situated near the southern tip of India, getting from Karaikal to other locations in India that had cleft palate missions going at the time proved too difficult for residents of the area. A key proponent for the mission, Raghavasamy first proposed and then began soliciting, support for a mission that would benefit the children of Karaikal. The groundwork for the first Rotaplast mission began three years prior to the 2004 mission. Three years of effort, coordination, and cutting through government red tape finally paid off and the first mission arrived in January of 2004.
The Tsunami of 2004 hit before the second Rotaplast mission arrived in 2005. Part of the hospital was damaged and wreckage from the pathology lab washed ashore several kilometers away. The Rotary Club of Karaikal continued to prepare for the arrival of Rotaplast while conducting tsunami recovery actions. In coordination with the government, Rotary International, and numerous Rotary clubs around the world, the Rotary club of Karaikal built more than 20 new homes for victims of the tsunami.
A Monument placed in front of more than 20 homes built by the Rotary Club of Karaikal in conjunction with District 2980.
Local Rotarians arranged for a day of sightseeing in the Karaikal area for the team to relax and take a break from surgery. After morning rounds, the team traveled by bus to Chidambaram to visit a Hindu Temple. Taking more a thousand years to construct, The Thillai Natarajah Temple, Chidambaram, is dedicated to Shiva, the Lord of the Dance. Photographs are allowed on the outside of the temple only and all visitors must remove their shoes prior to entering. The paving stones are black and the sun is extremely hot causing team members to actively look for shady spots in which to stand.
A sidewalk shop selling figures of various deities
For our recreation and pleasure, the Rotary Clubs of Chidambaram and Karaikal arranged for motor boat tours of the mangrove swamps near Chadambarum.
No Rotaplast trip would be complete without…..Rotary Meetings! The Rotary Club of Chidambarum graciously moved their meeting date to coincide with the visiting Rotaplast team. We exchanged Rotary club flags and pins and then shared a meal together before driving back to Karaikal for a Rotary meeting with the Rotary Club of Karaikal. In addition to exchanging flags and speeches, the Karaikal Rotarians also brought their families and two birthday cakes to honor Frank Walchak and Allen Shirely who both celebrated their birthdays while on mission.
Lisa Teske, Rotarian from Tri-Cities Coumbia Center Rotary Club exchanges flags with the president of the Rotary Club of Chidabaram.
Frank and Allen cut their cakes while the audience sings the Indian version of Happy Birthday.
Our patients aren’t just numbers on a chart, they have names and faces and stories to tell. Too often, in the effort it takes to treat as many as we can in the short time that we have, we lose that personal touch and we don’t hear the thoughts, fears, and hopes of those we treat.
I first noticed Saraswathi as staff ushered her into the PACU to see her baby, Kalliyappan, in the first moments as he awoke after surgery. From the moment she entered the room, Saraswathi beamed with an infectious happiness. She stood patiently by waiting to hold her baby once again while Bruce and Wendell ensured all the vital signs looked good. Satisfied with the baby’s progress, Bruce gently placed Kalliyappan into the waiting arms of his mother. The joy and wonder of this mother touched me and I made a note to visit with her the next morning during rounds.
The next morning, before rounds had started, I ran into Saraswathi who was even more excited than the day before. Through the interpreter, I learned that the baby had made the “m” sound for the very first time just after waking this morning. The Tamil word for mama is “amma”. Kalliyappan had been making the “ah” sound for some time but with the cleft lip, could not make the “m” sound. Nothing pleases a mother more than being called mama, or in this case, amma for the first time. Kalliyappan is already demonstrating the fruits of the lip repair.
Saraswathi and Kalliyappan came from the town of Tirupur and traveled more than 300 kilometers and 12 hours to get to Karaikal for the surgery screening. They’d heard of the upcoming Rotaplast mission from a local Rotary club and attended an initial screening when Kalliyappan was little more than three months old. Kalliyappan was born with a cleft left lip.
Kalliyappan is small for his age weighing only 3.5 kilos or 7.7 pounds and not thriving due to the difficulty in feeding. He’s happy and active though. and rarely cries. His bright eyes follow movement and sounds and he grasps with surprising strength for such tiny hands. In every other way, he’s a beautiful baby boy.
I asked Saraswathi what a surgery like this means for her and the baby. The first thing that came to mind for her was that now she would be complete as a mother. When asked what that means she explained that Kalliyappan hadn’t been able to breast feed due to the cleft lip, he simply wasn’t able to make a good latch. In her society, a mother is expected to breast-feed her children and if she cannot, she’s not considered to be a good mother. It didn’t matter that since he was born, she’d been expressing her milk and feeding with a syringe. Her own self-image suffers from the lack of ability to breast feed.
A little research into some of the Hindu religious beliefs around breast-feeding to gain a little better understanding of the cultural background: Sushruta Samhita describes the power of breast milk. “May four oceans, full of milk, constantly abide in both your breasts, you blessed one, for the increase of the strength of the child! Drinking of the milk, whose sap is the sap of immortal life divine, may your baby gain long life, as do the gods by feeding on the beverage of immortality!” (Susruta, III, 10).
With this as a cultural background, it’s no wonder that there can be a feeling of inadequacy.
The inability to breastfeed hasn’t been the only challenge. In this culture, the first-born child must be male and be perfect because that child will eventually be responsible for the care of the whole family in their elderly years. Saraswathi earned the wrath of her mother in law for producing a defective baby who, due to his defect, couldn’t possibly provide for them later in life. The discrimination he would face would make it impossible to get a good paying job or receive and education for a chance at a profession. Her mother in law frequently curses her and abuses her in ways that are difficult for us to imagine for giving birth to a defective child.
The mother and child are staying at the hospital on a tiny hospital bed for nine days in order to attend the final clinic. They simply live too far away and the travel would be too expensive and difficult for them to travel back and forth for the final checkup. The post-operative ward is hot, crowded, and noisy. It’s a difficult place to rest for short periods and yet this little family will be here for more than a week. Through it all, I’ve never seen her without a smile and a happy greeting. She’s used a sari to make a hammock for the baby which keeps him snug and happy. She thanks every Rotaplast member she meets.
I asked Saraswathi again, what the surgery from Rotaplast means to her. To her, it means a chance at a normal life. It means a chance at acceptance from the family and the community. For the baby, it means a chance at a future without discrimination.
Long before the Rotaplast team arrives, local Rotarians begin spreading the word about the upcoming clinic. Rotaplast spread the word far and wide and it’s amazing just how far the word travels. Many of these people have traveled long distances; some have traveled by train for as long as three days from Calcutta for their chance to be seen by the Rotaplast team. It speaks volumes, both about the need that Rotaplast meets, and the reputation the teams have.
Patients and their families begin lining up in the early morning hours. In a short ribbon-cutting ceremony, we welcomed the first patient of the 2012 mission.
The intake clinic is an exercise in controlled chaos. Imagine 85 patients, each with two family members, 28 Rotaplast team members, and 20 Indian medical staff all trying to work in a one room clinic in 95 degree heat and 95% humidity. The noise can be deafening at times with crying babies and the added trouble with translating because everyone seems to think the louder you are, the more easily you’re understood.
Patients begin with administration, filling out forms, and giving basic demographic information and then get their photos taken for their medical records. Patients then move through vital signs, dentistry, pediatrician, surgeon, and anesthesia. In addition to screening, intake day is the time to develop the plan of action for surgery and scheduling.
Clinic begins with a visit to Lisa Teske the Medical Records Specialist. Then it’s off to have their picture taken by Dave Windom, the photojournalist.
In some cases patients are turned away because they have a pre-existing condition such as a fever or other infection, airway difficulties such as colds or asthma, previous reactions to anesthesia, and heart conditions can all lead to a very disappointed patient being turned away. The team uses the standard of 10,10,10 rule to ensure that the patient is ten weeks old, 10 hemoglobin, and a weight of ten pounds to determine the safety of anesthesia and surgery. It’s heart breaking to turn someone away who has traveled so far and has such an emotional investment in getting life changing surgery, but precautions have to be taken.
The tension and stress can run high on intake day. Parents and kids are scared yet very much driven to get “a beautiful smile.” Kids get tired of being poked and prodded by teams of strangers who speak a different language and tend to get a little cranky by the end of the day. Eventually, it all comes together and a schedule is produced, patients are told when to report back, and the team puts the operating rooms together for the next day.
One of the greatest rewards of being a Rotarian and volunteering with Rotaplast is the opportunity to meet, work with, and create fellowship with Rotarians from around the world. To say that fellowship makes for understanding, and understanding makes for friendship, is certainly true. To meet fellow Rotarians at a conference is certainly valuable, but nothing beats meeting Rotarians where they live, and sharing the experience of working together for a greater purpose. It adds deeper meaning to “Peace Through Service.”
One of my first observations after getting off the bus is that the Rotarians of the Rotary Club of Karaikal are exuberant, and it showed as they greeted us with music and flowers, with smiles and handshakes. The excitement and warmth of our hosts was a welcome tonic for weary travelers
Medical Director Frank Walchak is greeted by Rotarians from the Rotary Club of Karaikal as we entered the Paris International Hotel.
Head Nurse Debby Dean, RN and Ian Yuan, MD Anesthesiologist look on as the greeting ceremony takes place .
The importance of ceremony, celebration, and tradition cannot be understated here. After a quick nap and a short tour of the hospital facilities to plan the next day’s activities, the Rotarians and the Vinayaka Medical College and Hospital treated us to the Rotaplast Mission 2012 opening ceremonies. The hospital is a teaching institution and, in honor of our visit, canceled classes for the afternoon of our arrival so that the students could attend and perform in the opening ceremony. Students performed with traditional song, dance, and music.
All those whose efforts contributed to the success of the mission were honored. Mr. Terri Paul, Rotarian from the Rotary Club of Karaikal, addresses the audience.
Medical students fill the auditorium for the Rotaplast 2012 Karaikal Mission.
Gina Brown, RN, OR Nurse, and Mary Hoffman, Medical Records Assistant, wearing welcome garlands.
Because Vinayaka Medical College and Hospital is a teaching hospital, the team interacted with medical students throughout all phases of the patient treatment plan. As I worked my way through the hospital it seemed as though wherever a Rotaplast medical volunteer was, there was learning happening. Medical students, residents, and staff, participated in educational sessions and surgery. They were invaluable when working with the language barrier that complicates treatment, especially in the patient intake clinics which are typically noisy, hot, and chaotic. Having those friendly, competent local students eased the stress for both patients and the staff. Their assistance was greatly appreciated!
Amie Shaw, DO, and team pediatrician, leads a learning session with medical students from Vinayaka Medical College and Hospital.
Just one week after the Nagamangala, India team returned home after their mission, the Karaikal team began their adventure to India. Most of the team met in San Francisco, although we picked up members in Dubai and Chennai as we traveled around the world, or, in our particular case, over the world. Our plane left San Francisco and flew directly north coming within five degrees of the north pole before flying over Russia and Iran to land in Dubai.
Mission Director Tom Fox briefs the team on what we could expect for the trip and what safety precautions we needed to take. The medical folks discussed the steps we needed to take to stay healthy and capable of fulfilling our mission.
Getting to Karaikal isn't a simple process. The team flew over 15 hours from San Francisco landing in Dubai in the middle of the night. After a short layover, the team flew on to Chennai, India to clear customs and load our equipment onto a bus and truck for the six hour trip by road to Karaikal on the southeast coast of India. By the time we arrived at the Paris International Hotel in Karaikal, some members had been traveling more than 48 hours.
Getting anywhere with all the medical equipment is never an easy task. The team is allowed one checked bag so that the rest of the luggage is medical equipment. "What you need, you bring with you." Just the gear and baggage filled one truck.
A very warm welcome from the Rotary Club of Karaikal awaited our team.
India can be a shock to the system. The moment you leave the airport all five senses go into overload. The sights, the smells, the constant honking of horns, and the crush of people and animals reminds you that things truly are different here. There is stark poverty and yet there is great beauty in the splashes of color and the faces of the people. Seven hours on the bus gave us ample time to soak in the sights and sounds that are India.
The team arrives tired from almost two days of travel but eager to get started.
Once we arrived in Karakail it didn't take long to get to work with the business of Saving Smiles and Changing Lives. After a very brief rest, the team traveled to the hospital to begin putting together the plan for the intake clinic the following day.