– Program Director Article –
Our Program Director, Alice Williams (far left in center picture), ventures to Grenada for a Mission Trip
RASA Training Note: We are proud to have you on the RASA Team!
Be sure to check out the bottom of the page to see the fun Alice had after a hard day’s work!
As a Certified First Assistant, you may be minding your own business one day in the Operating Room when a surgeon will walk up to you and say, “Would you be at all interested in going on a surgical mission with me?” This happened to me this past summer and on November 25, 2012 myself, a pediatric eye surgeon and two of her office staff embarked on a Pediatric Ophthalmologic mission to Grenada. Our primary focus would be on pediatric and grade school level children with issues such as strabismus.
Grenada, known as the “Island of Spice” is an island country consisting of the island of Grenada and six smaller islands in the southeastern Caribbean Sea. It is one of the world’s largest exporters of nutmeg and mace, cloves, ginger, cinnamon, allspice, orange/citrus peels and cocoa; nutmeg leads at 20% of the world supply. Grenada is 133 square miles in size and has an estimated population of 110,000 comprising of citizens of African, East-Indian and European descent. The residents speak English, so this was very helpful to us. The climate is tropical and true to form was quite hot and humid while we were there, with the temperature averaging about 88 degrees. Our destination was St. George’s, Grenada and we would be housed at the University Club which was located a few miles away from the Saint George Hospital, the Cardiology Clinic and the St. George’s University. The University Club houses visiting professors who will teach at the university or work at the hospital. The University features graduate and undergraduate programs in Medicine (established in 1977), Veterinary Medicine (established in 1999) and Arts and Sciences (established in 1996). In 2008, the School of Nursing opened. Degrees in public health and business are also offered.
Our Mission was hosted by Orazio Giliberti, MD who established St. George’s first eye clinic on the Grand Anse Campus and was in fact the first St. George’s graduate to specialize in ophthalmologic care. Dr. Giliberti provides medical services to both the University and the local Grenadian community while continuing to engage in charitable work on the island. Dr. Giliberti also serves as Associate Dean of Clinical Studies and the Director of Ophthalmology at St. George’s University while maintaining a private practice in Totowa, New Jersey. He and his daughter, Francesca Giliberti, MD co-manage the Ophthalmologic Clinic.
A brief introduction of the team members of this mission include Ingrid Carlson, MD, Pediatric Ophthalmologist, Amy Forsh**, Linda Ninesling** and myself as CSFA. Joining us from New Jersey (arriving late Tuesday night from Haiti where he was on a previous mission) was Robert Dorian, MD, Pediatric Anesthesiologist. Since my services as First Assistant weren’t needed until Wednesday, I made myself busy sorting through the medical supplies, equipment, donated eyeglasses and assorted toys to hand out to our little patients as well as providing photographic documentation of the events.
Our patients had been triaged before our arrival and although we were prepared for surgical repair of strabismus, we also were greeted with a variety of other eye ailments. The first day we saw 40 patients with issues such as strabismus, congenital anophthalmia, collosal dysgenesis, coloboma, optic nerve hypoplasia, proptosis, subluxed lenses, cataracts, glaucoma and a case of accidental blindness from a machete injury (not something we see much here in the US!). The children were very well-behaved and polite and nearly all of them allowed us to place drops in their eyes for dilation and more definitive examination. On occasion, my services were called for to help hold an unwilling child when the drops were placed. We didn’t really have time for lunch, but grabbed a nibble now and then when we could. Examinations were performed and some children were prescribed and fitted with eyeglasses and/or eye patches while others were scheduled for surgery. At one point during the day Dr. Carlson and I were interviewed by the local TV station. Apparently many in the television viewing area with eye issues saw the interview and wanted to take part in the free eye exams being offered by the American doctor! Word travels quickly on the island and on more than one occasion during our stay in Grenada, we were recognized by a driver or someone we casually met from our brief television encounter. Little did we know it but we were about to find out just how many Grenadians saw the news clip.
We planned our second clinic day to be held at the Eye Clinic in the St. George Hospital. Upon arrival, we were directed to two small (hot) rooms where we would conduct examinations similar to that of Monday. It was quite challenging because there was no space for our supplies and it was extremely difficult to route the patients through our small area. Gratefully, our trusty Grenadian office coordinator, Tracyann, organized our schedule, routed the patients through the maze of examinations and lab work and generally kept us out of trouble. When you are in a situation like this, you simply make do with what you have and carry on. There were dozens of children’s eyeglasses donated by the local Lyon’s Club in Colorado Springs. They had to be sorted out and organized with no available space to do so. Seeing children as young as eight years old with glaucoma and cataracts is very disconcerting to say the least and many of our little charges presented with such. There seemed to be a large number of Marfan sufferers on the island as well; one of the manifestations of their disease process is subluxed lenses, which would require a vitrectomy at a later date as we were not prepared to perform these. This day we examined 36 children and scheduled more for surgery. We are anticipating Wednesday, Thursday and Friday as surgery days and will then schedule a follow up clinic on Monday for post-op visits and any additional examinations that we couldn’t complete today. Any potential surgical candidates would be placed on the next visiting Ophthalmologist’s schedule! How’s that for job security?
It’s Wednesday morning and we have our first operating room schedule with five patients. We actually had seven patients arrive which demonstrates just how flexible our surgical schedule has to be! They were actually scheduled for Thursday or Friday and came the wrong day, but we have no intentions of turning them away. We’ve organized our room by 9:30 but will have to wait for the instruments to be processed in the autoclave. There is only one autoclave to service the entire operating suite of five rooms with a processing time of approximately 25 minutes. There are about 17 nursing students and assorted anesthesia personnel in our room to observe our cases, so things are a little chaotic to say the least. Dr. Dorian, our Pediatric Anesthesiologist, begins his day by inspecting the equipment and fixing what needs to be fixed and familiarizing himself with the older anesthesia machine, as well as setting out his own supplies. In addition to being the equipment troubleshooter, he quickly slips into the role of teacher and mentor and readily engages the students in anesthesia fundamentals, as well as share his knowledge with the resident Anesthesiologist at the hospital. Dr. Dorian was enthusiastic and obviously enjoyed his role of teaching as well as his primary role of anesthesiologist. He was truly a great match for our team!
We were instructed by the Grenadian surgical technologists to put our scrub hats on before our scrub tops. We comply, although we are not sure why this is required. We are visitors after all, so it’s important to remember “when in Rome…” The rolling stools don’t roll as they are all old and rusty. This is very tricky in eye surgery, as a stool that won’t smoothly roll you up to the patient can result in a minor earthquake, which of course is a major earthquake under loops! This was an obstacle we had to overcome and I couldn’t help but think how great it would be to have a can of WD-40!
The nurses separate the children from their parents quickly upon arrival in the pre-op area. It seems as if the children aren’t watched quite as closely in post-op as they are in the States, where several nurses surround the bedside and are never a step away from their patients! The kids are amazing. There is very little crying and nearly no fussing. There are no warm blankets. There is no hand-holding. And guess what…they do just fine! They are all little troopers.Our first case of the day finally started at 11 am. We had a lengthy wait before our patient could be extubated and moved to post op due to equipment issues, and by 3:35 pm we’d only finished our second case. In the US it would take us an hour to do a case, 20-30 minutes to turn the equipment over and get the room ready for the next case. When you are in an under-served and unfamiliar area such as this, you really have to “go with the flow” and not expect things to run as smoothly as they do in your customary situation. Our last case started at 8:30 pm. We left the hospital late that evening, exhausted but at the same time happy and grateful that we were able to provide this service and care for the children.
Our second OR day began at 9 am with four patients on the schedule. Our third patient arrived, however, was spotted having breakfast and had to be postponed until Friday. Despite our best efforts at setting a schedule, our experience here on the island is that some patients just don’t show up for surgery, or they may appear on the wrong day, or they may eat a meal. In any event, we will just try to fit them it as best we can and “go with the flow.”
Our last surgery day, Friday, shows a schedule of five patients. While five patients isn’t a hard schedule to fill in the States, here it is another story! Looks like another long day for us. We were surprised when we arrived in the OR, as the entire unit was empty! There were no scrub techs and no personnel of any kind that we could see. Upon investigation, we found out that our patients were downstairs in the eye clinic and weren’t allowed to come up to the OR until they had been processed there. (The Operating Suite is on the third floor and the eye clinic is on the ground floor). It’s 9 am and we are second in line for the only autoclave in the department.
By noontime we have just finished our first case. One important thing to remember when you are in another facility in another country, is that things just don’t work the way they do back in the States and you must adjust your expectations for this. We have another hour delay as there was already something in the autoclave so we’ll just wait for our instruments to be processed. Watching the nurses in the room is fascinating in that a sterile pillowcase is slipped onto a mayo stand in the morning and left there for the remainder of the day; no matter how many cases take place. Transfer forceps (sterile) are used to place towels over the draped “sterile mayo” and this is performed for each case. There is one small trash bucket on wheels that regularly gets emptied and washed. Curiously, instruments are re-wrapped in the operating room after being decontaminated in the sub sterile area. This would not happen in the US. It is now early afternoon and patient number two has just been anesthetized. We are finally finished with our cases and cleanup at 9 pm and we are waiting for our ride outside the hospital entrance. To say the least, we are truly exhausted. Apparently, our bus back to the University Club already arrived at the hospital twice and left again because we weren’t outside waiting for it. This is a common occurrence with island living and really makes you appreciate having your own car as much of the transportation is via city buses, university buses or the good old foot!
It’s Monday and we’re returning to the Cardiology Clinic to see post-op patients, a few patients that we had to turn away from Tuesday’s clinic and several new patients. When we arrived at the clinic once again it was already jammed with patients. We started our day around 9 am with post-op patients mixed in with new patients. I resumed my job of passing out toys and taking pictures. A number of our patients wanted to give us all a hug before they left. This was such a sweet gesture and made us all smile. Their eyes looked so awesome and they will undoubtedly be much more confident and outgoing as a result. This is a beautiful thing to be a part of.
No matter how many patients we saw during the course of the morning and early afternoon our waiting room remained as full as it was upon our arrival. We finally discovered that the Ministry was sending patients to our clinic without telling us they were coming. It seems that this is how things work on the island. There is very little, if any, communication between our Clinic and the Ministry. We are left in the middle to explain why we can’t see all of those who are waiting. “God please help us to do what is right; care for those in need; be kind to all -even each other- and provide all we can for those who have been sent to us.” Amen. We have come to realize that the need here on the island is great and the resources are small in comparison. I honestly believe that if we had kept the doors open, the patients would have continued to file in!
By the end of the day, we’d seen a total of 44 patients and all 13 of our post-op patients. Our surgical patients all did great and the kids are all smiles and so happy that their eyes are straight! This is such a great thing to see as many of these children are ostracized and teased and some are not even allowed to attend public schools because of how their eyes look, despite their normal intelligence levels. It’s a wonderful thing to see such gratitude from both the parents and the kids and makes our mission work so gratifying.
It’s Wednesday and time for us to pack up our equipment and locate the nearest Fed Ex office. It is pretty costly to ship equipment out of country and thankfully, we only had two small boxes to ship back as compared to the five or six large boxes shipped for our use! We had time after for a little souvenir shopping and a walking tour by a Grenadian “ambassador” who supplied us with a lot of historical facts and anecdotes of the island. By the way, although we didn’t spot Kirani James, the Grenadian who won the 400 meter race in the 2012 Olympic Games held in London, we passed the street named in his honor on the way to the hospital each day: “Kirani James Boulevard”. He was very revered on the island and by all accounts was one of the nicest and humblest heroes of the island. He was also bestowed with government bonds totaling EC500,000 ($185,185.00 in US currency), a commemorative stamp in his honor, a new stadium bearing his name and an appointment as Tourism Ambassador!
In summary, I would have to say that this was a wonderful experience serving the children of Grenada and easing the minds of many worried parents. We basically took care of the strabismus issues and a few minor issues, but the need is great for many other surgical and medical problems. Our scheduler informed us that there is another Ophthalmologist coming to the island in a few months (although not a Pediatric Ophthalmologist) and some of our clinic patients were put on their schedule. It’s critical that you approach a trip like this with a very open mind and heart and realize that things are done very differently than what you may be accustomed to. Your job is not to try to change the way things function; you are there to provide a service that they do not currently have available and do the best you can and serve as many as you can, given your time constraints. The hardest thing for me personally was to leave the island knowing that so many more children (and adults) could have benefited from our skills and knowledge and we just didn’t have the time to fit them all in.
Update 2016: Alice was married this year and now goes by Alice Dungen! Congratulations!