The Perfect Smile

Salvador was born with not just one harelip, but with two gaping holes in his upper lip through which his crooked teeth peeked like a grotesque pair of eyes. All his life he was tormented, treated like a monster. Instead of seeing his face as a cruel accident of nature, most of the people around him considered Salvador’s face a judgment from God—punishment for his parents’ sin when they conceived him. He had stayed inside his home in the barrios of Mexicali since his birth, rarely venturing into the outside world.

My original personal sketch of Salvador’s face

Mexicali was the site for the first Interplast surgery trip. We chose Mexicali not because it was a garden spot, nor was it a resort destination. The capital of Baja California, Mexicali sits right on the border fence, in the inhospitable Desierto de Altar. It last rained there three years ago. Summer temperatures go to 114° without anyone remarking, “it’s unusually hot today.” A group of 500,000 people are drawn here. Mexicali was built only in the last fifty years because of the agricultural opportunity: part of the remaining Colorado River agua flows to Mexico as part of a deal with the neighbor to the north. The All-American Canal to southern California runs actually south of the border here for several hundred feet, flowing quite near the cardboard-packing-crate homes of the newly arrived emigrants from Oaxaca, El Salvador, Honduras, Nicaragua, and Guatemala, hoping for work at the malacodores, tax-free factories. The hard-packed clay always smells something like liquid excrement to me whenever I am within two miles of this, my second home, and I hope that the urine odor is from the stockyards that fatten the beef with Mexicali grain, alfalfa, and sorghum.

It was thought that Salvador could not have a worse problem—until the day, when he was seven years old, when the Interplast doctor in a white coat, an American pediatrician, said to Salvador, “You have a heart murmur, and we shouldn’t operate because the surgery will be dangerous.” To Salvador’s mother, Julia Anita, these words were received as a sentence from a judge would be. But she did not want to settle for the “no” answer. Six months later, she and Salvador were in line at the next Interplast clinic rendezvous in Mexicali. Perhaps the pain was more severe on the occasion of his second try for surgery. But alas, a second pediatrician used the same words. And without availability of sophisticated diagnostic equipment, cardiac catheterization, and EKG, we all assumed that an impasse was in sight for Salvador; all except for his mother, She brought him for try number three a year later, when Salvador was nine. She had love for her child in infinite proportions—as most other most other mothers in Mexicali, she was committed to helping Salvador in whatever way she could. She knew that he had only one friend, one advocate in the world: herself. And it was then that the third Interplast pediatrician furrowed his brow as his stethoscope brought the swoosh, swoosh, swoosh of the heart murmur to his expert ears.

The mother could not hold back: “Doctor, Salvador has only one chance for a normal life. He has been turned down twice. Without surgery he is nothing—it is worth the risk! Please, please, doctor, give him the chance!”

Dr. Kent Garman, most brilliantly trained senior resident at the Stanford department of anesthesia, and Dr. Lorne Eltherington, nationally reputed professor of anesthesia, recruited (stolen) from the University of California at San Francisco to Stanford and Interplast, as well as Dr. H, Dr. L, PC, George Chippendale , Dr. Terry Knapp, Nurse R , Nurse E., and Dr. Z. discussed the pros and cons of the “case,” the nine-year-old with a bilateral cleft lip, a social and physical impediment to his entrance into the human race. We mulled over the ever-present risk of complications, the methods to be used to minimize problems, the talent amassed for the boy’s help at this particular moment in medical history, the inability to pursue further diagnoses, the social aspects, the psychological aspects of each one of the stakeholders involved. . . What is God’s plan here? Should we put our reputation on the chopping block in favor of another person who is asking for his own passport to a normal life? Back and forth went the process of decision-making. And I decided. That was how Salvador was given his chance.

He was evaluated even more carefully and diagnosed with an atrial septal defect—not a severe heart problem. His condition did post a surgical risk, but the treatment team concurred that the risk was not great. There was maybe a two percent chance of complications.

The best equipment was already unpacked—sterile instruments that we sterilized again; we set up the electrocardiogram, the PO2 meter, CO2 monitor, and the backup blood transfusion. The lab work had been checked. Salvador had had several exams. He had been through intake personnel of Mexicalenses, gringos, and volunteers at many levels.

We had done our politics, established our human relationships over three years of visits, meetings, and correspondence with new friends and with many agencies at all levels. We were well prepared in every way to help patients, to teach, and to eventually turn the teachers into providers for other countries. Idealism was wild in the atmosphere. Just as our forefathers were as they set out to search for deer or pheasant or woodchuck, we were loaded for bear. To continue in the metaphor, this meant we had the equivalent of a big caliber gun, plenty of ammunition, plenty of protection from the attack of a bear, and plenty of knowledge about the bear’s habits, the wind direction, etc. We had prepared for eventualities.

Induction of anesthesia, the most risky event in Salvador’s life thus far, was absolutely uneventful. Not one, but two anesthesiologists both superior in grade and soon afterward to be nationally acclaimed in their own rights neither saw, heard, nor felt any indication of danger. Thus we all approached the case with enthusiasm.

“Let’s go,” I said, reflecting the collective voice of the team.

I had selected Terry Knapp be the lead surgeon for the third case on this Saturday. He was turning out to be larger than life in all spheres: surgery technique, organizational ability, intensity, irresistible quest for self-improvement, humor, ability to relax at the party, and more. He was one of the four founders of Collagen Corporation during his residency.

“Position the head, Terry. Cleanse the skin, Nurse R, and place the sterile drapes.” Now the blue marking lines went on, and Terry and I remeasured the geometric pattern to the 0.75 mm tolerance. We explained the plan to those in the room who wanted to learn at their level, the medical professionals from both countries and the paramedicals and go-fers. Among those present in the room, there were all levels of those who desired acquisition of the psychomotor and cognitive skills of cleft lip repair. Indeed, all levels of the appropriate behavioral attitude were represented, and all the various methods of communication were operative—Spanish, English, body language, social hierarchy, physical touching, even subconscious and between-the-lines transfer of information. All were eager to teach and learn from each other in our own areas of competence. (continued below)

A simplified illustration of a bilateral cleft lip repair procedure. The cleft is a fissure dividing skin, muscle and mucosa. The repair involves loosening and freeing these tissues up with wide dissection into three layers. The repair recruits these existing resources to reconstruct an anatomically normal lip. Repairing the muscle is most important, as the repaired muscle pulls the cleft together to bring teeth, growing parts of tissues and skin together. The art is in freeing up the tissue while maintaining blood supply for healing and growing. Thus, the lip is placed into anatomic position. Later, the nose is changed to a projecting tip using autogenous cartilage as the building block.

“Sponges, please. Terry, make the skin incision with your smallest scalpel.” I gently put the plastic surgery hooks on the little flaps, getting ready to interlock the muscle layer, the mucosa and the skin flaps. Terry was ready to place the initial sutures to form the foundation of the construction. We had opened the entire lip and extended the loosening up, undermining out over the cheekbones almost to the parotid glands in front of the ears.

“Wider yet, please, to free up the muscles. Be just as careful as the Sierra Club.” That was understood to mean do no harm, be gentle and fine, and when you leave there should be no trace of surgical trauma. Take only photographs.

Now the entire face was open and what one saw was red tissue not anything like a human face—more like a war injury than our finest work.

“Okay, everything is ready for the reconstruction.” The jigsaw puzzle was set for assembly. “A 4-0 chromic suture, please. Oh, excuse me: Cuatro-cero crómico, por favor.”

Everything was going great as we broke new ground in about ten different ways. But suddenly,

“Boys, we have no pulse.”

Words that I will never forget.

Salvador’s appearance moments before death

“Oh God! This child is dead. Action!” is the conditioned-reflex response to that information. In three seconds the checklist was accomplished in staccato timing:

• I take the sterile drapes off the child and check the airway.

• Is the endotracheal tube in place? Is it kinked, clogged, or full of blood?

• Is the blood blue?

• Is the carotid pulsing?

• Listen for heart sounds.

• Is the O2 really flowing into the lungs and is the blood oxygenated?

• Any mechanical problems with the machine?

• Start external massage, pushing down on the chest to squeeze blood in and out of the heart.

This is the algorithm we automatically go through in a matter of a few seconds.

I now recall my thoughts: Oh dear, why did I become a doctor in the first place? Why go out of the way to take chances, to go to Mexico? You’re out of place. Oh shit. Oh dear God if this child lives I will be good the rest of my life. I’ll work for the good of other people…

“Kent and Lorne—look at the EKG. Is there any electric action? Is there fibrillation?”

“No. Flat line. Flat line. Flat line,” they noted.

“Okay, stimulate with intracardiac epinephrine and give bicarbonate to reverse acidosis. Let’s give a swift blow to the chest to stimulate the first heartbeat.”

The anguish of a child dying, and it’s your fault. Your responsibility. But the guilt competes with the immediacy of forming a plan. My mind went, how will I get out of jail in a foreign country? What can I say to his mother? What can I say to my mother? What are the resources here to help out in this situation? How can we save this child’s life? Why is this happening? The mind races at 1000 mph. What could I have done differently so this child would have a life? Oh, this is awful, awful, awful. But let’s do whatever is needed now…

One hour later we were out in the hallway with  the mother and Dr. G-C, our Mexican sponsor, and PC, our coordinator extraordinaire.

Gulp. I looked into Julia Anita’s eyes and my eyes flitted off to the wall, then back to her. Gulp again. “Señora, tuvimos problemas, cumplicaciones muy graves. No exito; Salvador moriro.”

Her tears were explosive. We were both in that same ten-second period gripped together, yet alone. There was no past, no future in our consciousness. A part of our minds was surrealistically aware of incidentals—the trash on the floor, the smells of excrement from the ward room where six wounded, dirty, unshaven, bandaged, skinny men were struggling with their own medical threats to their lives, the occasional flying insect, the color of pure blue iridescent sky out the open window. Surrealism was present, and we were struggling with the worst tragedy in any of our lives so far. We became larger than life.

When Salvador’s mother looked at me and spoke quietly, Dr. G-C and PC translated her sad, gracious speech. “You needn’t be preocupado, so nervous, doctor. You and your colleagues did your job as well as you could. Salvador was given his chance and he won, because his lip is finally repaired and he will see God with a complete smile.”

I immediately thought, Oh my God! What more could we learn from this culture? This mother has so much more wisdom and grace than any American. She already has instincts in place to deal with the vicissitudes of life. We did not. I had yet to learn.

And then a split second later, Oh my God! His lip isn’t repaired. His face is a mess!

Terry Knapp had the same realization and jammed his elbow into my ribs—we both dreaded the mother’s impending shock and disappointment. She had such majesty despite her pain, despite her poverty; I couldn’t reveal the state of Salvador’s lip. His mother expected to uncover the pine box tomorrow morning at the funeral so that both she and God could appreciate Salvador’s complete perfect face. My contract with Julia Anita was unfulfilled. But it is against the law in both Mexico and the U.S. to operate on dead bodies. It’s considered mutilation.

Again, we conferenced as a team with personnel from two countries.

The team said, “This mother deserves the best-looking face we can make. Let’s go!”

This could have gotten us in real trouble. It could have created an international scandal. It was yet another risk, but one that was mandatory to accept.

As I walked back to the operating room, I went through my next moves in virtual fashion:

“Clean the face Nurse R and put the drapes on. Check the pattern of the flaps again. We won’t need any gauge sponges nor will we need anesthesia. There will be no bleeding this time. Gonchitos (small hooks), por favor. Cuatro-cero crómico. Seis-sero nylon.”

In 30 minutes we were all satisfied. “He is beautiful. Oh, look what you have done.” This is all I consciously heard, directed to Terry and me. And Howard Holderness, the resident, went out and put $10 in the right place to pay for the coffin. There was no elation, but we felt somewhat better now.

After dawn on Sunday we were at work again in the hospital doing surgery to fix cleft lips, more than normally aware now of the smell, the insects, the dirt. There was no sound except for the sigh of the steam autoclave as it opened its door to present pristine surgical instruments and the solitary clicking of the surgical needle holders at work. Nothing else. But at 9 a.m. our eyes and our minds soared out the open window and through the clearest blue sky to the burial place so that we could all be there in spirit as Howard and Julia Anita pulled back the cloth to reveal a complete face. In the O.R., we breathed in with all our senses—we were all virtually present at the moment of the mother realizing that she had completed the purpose of her life.

A promise fulfilled

The team completed eleven cleft lip and palate reconstructions that weekend, ten of them rather dramatic rehabilitative successes. The parents’ smiles when they viewed the now-normal faces of their children after surgery was enough psychic income for another year’s work, without a penny of tangible income. Money and EtOH are no match for the good feelings that come from psychic income. This is why we became doctors and nurses in the first place.

Monday arrived, and we were all back to work, dealing with the familiar input that was part of our jobs: “doctor, Mrs. James must see you immediately because her little suture is not right.” “Oh,” I said, and nothing more. Nurse R heard, “nurse, you have not filled out the last pile of your paperwork.” “Oh,” she said. Then Terry heard, “Doctor, your CPA, your insurance saleswoman, and their attorney would like you to return their important calls.” Howard heard, “Doctor, your investment advisor and your banker would like some thousands today. They say you will receive happiness and up to a 12% return on your investment.” My secretary said to me, “hey, Doctor, you are supposed to be answering these phone calls. Please don’t be dialing to arrange Spanish lessons. Are you listening to priorities? Hello? Helllllo?” We were all experiencing reverse culture shock in climbing back to reality that morning.

Happiness. What is it? I was happy as can be at this moment. I had been through an emotional canyon, an abyss indescribable. Psychologists say that at the time of a peak experience such as we had undergone, a person may undergo basic change in his value system. Here was a classic time for a peak experience. I suddenly had in mind a clear path; a grand plan. I had a mountain to climb, Goddammit. It was the start to a whole new life.

I was already imagining what I would say to the CPA, attorney, insurance person, administrator, bureaucrat, bill collector, patient, Mrs. James, and my collegial peers: “my slides are back and I have a nice idea to present to you. It is a very nice project that I would like to share with you at lunch tomorrow; I am sure you will feel compelled to participate and to donate to it in some way.”

Thus Interplast went on turbo acceleration in its development, and it gained momentum toward a goal to start a program to perform surgery for those who are disadvantaged and to teach those who want to learn about it. I felt compelled: This movement to help people who need help is meant to be. There was no decision, actually. There was no choice about whether to turn left or turn right. It was very much straight ahead, and even right up a brick wall if one should be placed in our way. The goal was established: 25% of plastic surgeons should participate in programs such as these. I then devoted ten percent of my time for the next eighteen years to building Interplast.

© Donald R. Laub, Sr. and Many People, Many Passports. All Rights Reserved. Some names have been changed and/or obscured to protect identities.

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3 thoughts on “The Perfect Smile

  1. Dr. Laub introduced me to international service in 1975 when he invited me on a mission to Mexicali the city he talks about in the above story. It was an experience I will never forget and I have been doing international service ever since. I owe him a debt of gratitude for enriching my professional life in such a meaningful way. I enjoyed his story very much and appreciate the incident he describes which has been experienced by others. Don Laub is a great human being.

    1. Angie,

      Thanks for the great comment. Don is one of the great influences of my life as well. I came to California in 1975 because of Don Laub and the program he created at Stanford. His work in creating Interplast inspired me greatly and I have dedicated my professional life to repairing congenital ear deformity in kids afflicted with microtia. “The Perfect Smile” is an incredible story written my an amazing, inspiring leader and fellow human being.

  2. I know Dr. Laub for at least 30 years, I have learned during the time I had the privilage to share with him, about his kindness and caring for all human beings.
    Fifteen years ago, I assumed the legal guardianship of a nephew who, as my sister, his mother; was born with cleft palate. She couldn’t take care of the expenses to help her son and I was able to help. I know what it is to go through the process seeing a beautiful child coping with cleft palate issues. I know about all the steps to go through reconstructive surgery, speech issues, emotional and psychological stumbles, and much more. My nephew, always so brave and positive, is now a young man fully recovered from his birth condition; he is a student with honors and he is looking forward to be a community leader and help the most in need.
    Dr. Laub’s work in building all those resources to help the children with cleft palate reconstruction in the most disadvantaged Hispanic and other communities has been remarkable and commendable. If we could have more Dr. laubs in the planet, our world would be a greater place to live.
    This story leaves a mixed emotion between the sadness of a loss of a child who didn’t have the opportunity to see his face as the way he wanted it; and the happiness to learned how a team of medical professionals restituted to this young boy his dignity beyond death. It shows so much caring and love for man kind. Gracias doctor Laub for giving us such a nurturing gifts as you have saved many lives!

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