Creating Smiles, Improving Lives

Morning, noon, night and morning: The care goes on and on

by John Paschal

The elevator opened, and Dr. Bill Gorman stepped slowly ahead.

“Draggin’ my wagon,” said the plastic surgeon, shaking his head and grinning as he moved from the hotel hallway and into the elevator en route to breakfast before heading to work.

The time: 5:57 on Wednesday morning, less than eight hours after Dr. Gorman had returned to the hotel after completing his ninth surgery of the Austin Smiles medical mission in Guatemala City. His mood was up, but his voice was hoarse.

And yeah, his wagon was draggin’.

“Pretty tired,” he chuckled as the elevator dropped.

It’s a good thing, then, that Guatemala is known for its coffee, because that beautiful black tonic has become a necessity on this mission, the 76th such trip in the 26-year history of the non-profit Austin Smiles. Some 20 minutes after stepping onto the elevator, Dr. Gorman stepped onto it again, heading up to his room before heading out in the van.

“Coffee?” he said, laughing as he brandished his white mug. “I took mine to go!”

Long days, short rest

For each of the four surgery days of the weeklong mission, when volunteer medical teams will perform nearly 100 surgeries at no cost to patients, the itinerary reads like this:

6 a.m. Breakfast at hotel opens

5:30 p.m. Conclude surgeries for the day

Reality might agree with the beginning of that schedule, but it merely mocks the end.

At 8:20 on Monday night, as the hallway outside the overnight rooms echoed in Spanish and English, I sat wearily in a cushioned chair. A red notebook, filled with descriptions that would never do justice to a subject I struggled to grasp, rested loosely in my cramped right hand as my eyes drifted into a thousand-yard stare.

At that moment, volunteer Pearl Falkenberg, whose identity had shifted from Lollipop Lady to Registered Nurse, playfully slapped my left knee as she walked briskly past.

“Are they kickin’ your ass?” she asked, almost cackling.

With just enough energy to nod, I did so.

Ten hours earlier, in the recovery room outside the ORs, eight-year-old Hellena Xuc Xoi is slowly opening her eyes after a primary palate repair with Dr. David Wainwright. In the adjacent bed, after a palatoplasty and BMT with surgeons Fred Wilder and Syboney Zapata, eight-year-old Felix Casimiro is beginning to stir. At their bedsides are nurses Cindy Thomas, Debbie Wilder and Angie Englert, along with volunteer Nickolas Prahl, 18, of Guatemala City, each helping to coax the kids to a new awakening, a lifetime of better health.

Of course, Hellena and Felix are only the first two of 63 patients scheduled for surgery across the next four days. Minutes later, just as anesthesiologist Dr. Stan Eckert bends down to give Hellena a soft high-five, volunteer Austin Lutz says to me, “Dr. Gorman is in OR1 with a massive cleft palate. He’s calling it the Grand Canyon. He started at 8:55 and is still going.”

Inside the OR, Henry Herrera of Moyuta, Guatemala, is on the table, his oral cavity held open by a retractor. Standing at the patient’s left side, the 6-foot-3 Dr. Gorman is towering above the 12-year-old boy, his large hands registering fluid movements as he works to make a put-together puzzle from spread-apart pieces.

“In our country,” the surgeon tells me while he works, “someone with a cleft palate like this would have it closed within his first year, so he could start speaking properly. Unfortunately, a child this age might not ever speak perfectly well, because he’s already developed coping mechanisms. But this will definitely help.”

That sort of help is what Austin Smiles has delivered since its inception in 1987, when Gorman and Wilder, along with more than a dozen other Austin surgeons, pooled their on-call money and deposited it in a bank account. In the quarter century since, Austin Smiles has conducted 76 medical missions in nine countries, ranging from Guatemala to the Philippines, with the assistance of more than $14.7 million in donated medical services, $1.25 million in donated medical supplies and 13,784 local-community volunteer hours. The result: 3,799 people with better-functioning palates, lips and ears, developments they might not otherwise have enjoyed. In Guatemala, 75 percent of the population lives below the poverty line, and 59 percent lack access to healthcare.

Back inside OR1, Dr. Gorman calls me to the surgery table. As “Bohemian Rhapsody” streams across the speakers, he directs my attention to Henry’s oral cavity, the tissue a healthy reddish-pink. “This is the uvula on the left side,” he says, gently prodding the small section of tissue. “It’s split from the right side. Right now I’m reconnecting it. I have to open it up so I have some tissue to work with.”

Assisted by CRNA Andy Seider, scrub tech Janice Ryan and nurse Stella Solis-Denny, Dr. Gorman continues operating in what can only be called a tight space, working to close the nasal suture line and the muscles of the palate in a cavity the size of a coffee cup. “The biggest problem with palates is that they’re in the mouth,” he says lightly, though he really isn’t joking. “There’s just not much room to maneuver.”

A few minutes later, as the Eagles’ “Take It Easy” streams across the speakers, Dr. Gorman directs my attention to the patient’s palatal flaps. One side moves nicely; the other is rigid.

“This side is tethered,” he says. “I need to dissect the tissue so it will move more freely.”

The clock hands are ticking. The music is playing. The suction tube drones.

Wearing a scrub shirt decorated with pigs piloting rocket ships, Dr. Gorman is patiently moving from one side of the patient to the other, his fingers moving as he goes. “We were looking right up into the nose,” he says, continuing the procedure. “Now we’re trying to move both flaps to the midline so I can close it.”

Two hours in, the surgeon takes a seat on a small black stool to continue his work. When he stands a few minutes later, the cable to the battery pack on his waist band snags, threatening to send his scrub pants plunging.

“Hey,” he says, his eyes going wide above his surgical mask, “I’m gonna look like a plumber!”

To the rescue, nurse Solis-Denny gives his pants an upward tug.

“Listen,” she tells me, with smiling eyes. “That’s nothing. There are places I’ve had to scratch.”

Literally whistling while he works, Dr. Gorman follows along with a Jimmy LaFave song as he continues to suture what was once apart, the pieces of the same puzzle that he and his team have patiently worked to solve. “Now we just need to put in a few more stitches so that it can withstand a teenager’s eating and talking and so forth,” he says.

At 11:55, precisely three hours after the procedure began, Dr. Gorman administers the final suture.

“All right,” he says, stretching his back. “What’s next?”

From chaos, order

On Sunday there was order in the chaos, with workers guiding kids and their families through the rooms and halls, but in truth, it seemed like chaos was just ordering the whole thing around. Children cried. Mothers waited . . . and waited . . . and waited. Always in haste, workers collided in the crowded hallways of the medical clinic, itself crammed almost impossibly between tiny tin-roofed residences in the heart of Guatemala City.

Monday brings an easier peace, the work more intense but the atmosphere more subdued.

Upstairs in the OR area, the mood is calm and efficient, cheerful yet businesslike. The dynamic is one of constant simultaneity, of concurrent and overlapping actions. Kids are wheeled in, kids are wheeled out, each in a different phase of repair. Endings bridge beginnings, and beginnings are always straddling a provisional end. There is a feeling of triumph, of finality, at surgery’s end; the surgeon scrubs out. Anesthesia is stopped. Smiles and nods are implicit demonstrations of “Congratulations, thank you, nice work.”

And yet another door is opening, and then another. Continuity isn’t a line; it’s a network.

In the recovery room at 12:15, Henry Herrera and Maycol Catalan, 3, are lying on their backs in adjacent beds. A day earlier, both were stoic, expressionless, betraying no emotion whether good or bad. Now Henry sleeps, peaceful in the earliest stages of his long recuperation. Maycol is beginning to wake, thrashing as he begins to cry.

“Mama!” he calls out as tears stream down his chubby, light brown cheeks. “Mamaaaaa!”

Nurses Debbie Wilder and Cindy Thomas lean toward him, as if naturally drawn to distress. They reach out. A hand caresses his head; another wipes his tears, strokes his face. Meanwhile, volunteer Nickolas Prahl is speaking gently to the boy in Spanish, coaxing him into some form of comfort.

In minutes the two nurses gently lift the boy from the bed. (It won’t be long before another child needs the space.) Maycol begins to whimper, somewhere in a whirl of wakefulness and sleep. A kind of surrogate mother, Cindy then sits in the wheelchair as Debbie places the boy in her lap.

“Shhhh,” Cindy whispers into his ear before kissing him on the forehead. “It’s OK.”

As Nickolas pushes the wheelchair toward the elevator, Debbie walks beside it while holding the IV bag attached to the boy’s arm. The elevator doors open, and then close, and then open again. Leaning from one wheelchair toward another, Cindy then eases the little boy into the waiting arms of his mother. “Mama,” he whispers.

The day becomes the night

At 6:05 p.m., darkness is descending on the city. The low clouds are crimson. From a perch, the rusted tin roofs run connected to a church dome and beyond, vanishing at a horizon that crawls to green mountain peaks. In the opposite direction, the conical gray crown of active volcano Pacaya fades from shadow to darkness. A dog’s bark is pulsing across the low and fading whine of a passing car, and then there is silence.

Indoors and downstairs, there is no silence. The overnight rooms are a din of Spanish and English, merged with the cry of a child. The boy is better because of the surgery, but for him it must feel less like recovery and more like fear. In room 1, Jefferson Morales is draped over the shoulder of his mom, Ena. Tears have streaked his cheeks. Across the hall, tiny Edgar Bamaca, only 11 months into life, is staring at his mother, Nancy, through half-closed eyelids. He makes no sound.

Leaning into the room, I give his mother a smile.

She smiles back at me, briefly, and then turns back to Edgar.

Back upstairs in OR3, two-year-old Katherin Garcia is lying on the surgical table, her tiny brown legs sticking out from under the blue gown. Kneeling at bedside, Dr. Eckert administers the IV in her right arm while his fellow anesthesiologist, Dr. Quint Barnes, stands on the other side while gently holding the patient’s left hand.

At the foot of the table, nurse Andrea Guidry covers the little girl with a blue blanket. At the head, CRNA Cathy Zaremba is handling the anesthesia machine, its flashing lights and numbers understood only by one who’s done it.

Seated on a stool, Dr. Zapata peers through an operating microscope and uses a curette to clear Katherin’s left ear of wax. “Sweet potatoes,” she quips, wiping the orange-brown wax on gauze. Then, even more delicately, she uses a myringotomy blade to make a tiny incision in the eardrum. As the doctor opens the incision to a width of one millimeter, the eardrum releases a dome of pale fluid.

“It’s so thick,” Dr. Zapata says, shaking her head. “We call it ‘glue ear.’ Poor thing, she’s just gotten used to it.”

After suctioning out the fluid, Dr. Zapata performs the most delicate procedure of all, placing a tiny plastic tube in the incision to allow the fluid to continue draining. “Instead of shoulder, elbow and wrist movement,” she explains, “it’s phalanges movement. It’s the tips of the fingers and the slightest wrist movement.”

To untrained eyes the procedure is a lot like building a ship in a bottle, only the bottle is an ear canal and the ship is an eardrum, and the eardrum is part of a tiny two-year-old child.

“She’ll feel so much better now,” the doctor tells me, just before moving to the other ear. “She’ll hear better, too, and because of that, her speech will also improve.”

Minutes later, after performing a frenulectomy to release the little girl’s tongue-tie, Dr. Zapata moves to OR1 to perform a BMT on the final patient of the night, six-month-old Sofia Argueta. Resting against the OR wall, I look on as the surgeon quickly completes the procedure. Relieved, I wait to hear the words, “OK, let’s call it a night.”

Instead I hear Dr. Gorman say, “Well, let’s get started on this little girl’s lip.”

The cleft lip, which from afar I did not notice, is waiting for the doctor’s hands.

The night becomes the day

At 7:25 on Tuesday morning, the doctors begin making their rounds. In room 7, Dr. Gorman sits on a stool to examine eight-year-old Maria Alvarez, on whom he performed an intensive rhinoplasty. Looking up, he peers into the girl’s bandaged nose.

“I would like her to leave this bandage on for one week,” he says to Dr. Ligia Figueroa, the MPSC medical director. Nodding, she jots the information and then conveys it in Spanish to the girl’s grandmother, a tiny, energetic woman who, like every other guardian here, slept overnight in a chair at bedside.

As a bit of blood oozes from Maria’s nose, the grandmother maneuvers around the doctor in order to swab it.

Dr. Gorman looks up at the grandmother and grins. Turning back to Maria, he gives the girl a hug before exiting the room. A few minutes later, after examining each of the 15 patients who underwent a total of 25 surgeries a day earlier, doctors Gorman, Wilder and Wainright gather just outside room 1. They look at each other and nod.

“We done?” asks Dr. Gorman.
“We’re done,” replies Dr. Wilder.
“Good,” says Dr. Gorman. “Let’s get to work.”

1 in 700 children are born with a cleft lip or palate

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