Mexicali is a splendid site, a beautiful site, and that is because we are attracted to and attached to challenge, to risk, and to stress. We are seekers, not avoiders, of these three forms of magic. We were attracted to Mexicali because it was one of the worst and most inhospitable places in the whole damn world, and for that reason medical and surgical care was scarce. You are able to see Mexicali coming up on a highway as a cloud from several miles away because the roads in 1966 were unpaved for the most part, and would remain that way for the next ten years.
The scent of Mexicali always gives me a feeling that I am almost home, to the place where I have gone with Interplast teams on more than 40 trips. It is a sign to me that I have arrived back where I have derived much pleasure. The smell is pervasive – not unlike that of the liquid excrement of mammals – and the ambiance is a little bit negative, but it is all okay because it is home.
With its tripartite objectives of direct care, on-the-job training, and long-term professional relationships, Interplast carried out their standard operating procedure of “plan A,” i.e., needs assessment, task analysis and signing a convenio prior to implementation, usually a several year process. The Interplast idea was to carry out these trips to do cleft lip and palate repair for those who had no access to this essential surgery gratis as a humanitarian act to “lend a hand.”
Our model was that we would travel on the weekend to accommodate the schedules of all concerned. We routinely would arrive on Friday night, usually on a private plane with a great comradely group of people who all participated voluntarily, including “Interplast Air Force” Chief Bob Bell and his copilot and the stevedore, George Chippendale. Pilots Henry Carstens, Bob Francis, and R.K. Johnson, a hand surgeon, and of course, the arch pilot Reed Dennis, the original Silicon Valley venture capitalist. Anesthesiologists, internists, pediatricians, post anesthesia care unit (PACU) nurses, and clinical care unit nurses were all vital to success. American residents in graduated responsibility levels in training complemented the Mexicali surgeons. Despite all the team members, room around the operating table was perfectly adequate to carry out the work and for on-the-job training to take place. Exchange of ideas between disparate souls flowed. Because of our common purpose, the educated, and the still-being-educated talked with each other. The program had originally been set up to fulfill my obligation to teach my residents. The best teaching method available in the world happened to be exactly here. These fortunate ones directly acquired surgical psychomotor skills. That is, actually did the surgery at a stage that had been heretofore very early in the training sequence. Thus, they acquired the baseline ingredient all-important for the next step: excellence in judgment. These nuances were easy to put into practice; because these “associates” had been selected for being in the “upper 0.001%.” of the bell shaped curve, they naturally soaked up the theories as they went along. The outcome of this teaching method was not unwittingly a very high esprit de corps,– because as you can imagine, the residents, on discussing their program at Stanford in comparison with that at other universities at national meetings would compare on only one criterion: how much surgery are they doing? And our crew would be probably two, three, or four years ahead in experience in “doing actual surgery”. So we were able to reinforce that they were the world’s best. I encouraged and augmented this propaganda in various subtle and unsubtle ways. In other words, we fed into their subconscious minds the feeling that they were superior surgeons and superior people. Everyone had a fine spirit.
In Mexicali, we worked in an older white colored building that had the appearance of a white board home, but was actually a 28-bed hospital for both jail patients and the poor. We worked for many days and early into the night in this little house, which really was our hospital.
“What are those little bugs that come around during the night?” Physician assistant Kees Ploeg would ask, because he stayed right there all night long on a wooden chair. “Cockroaches” a la the song La cucaracha, la cucaracha, ya no puede caminar, porque no tiene, porque le falta, una pata para andar (the cockroach, the cockroach, can’t walk anymore, because it doesn’t have, because it’s missing a leg to walk). Kees was there amongst ten sick or dying general admission patients, who lay next to post-op cleft patients. His duty was to watch for bleeding in these kids that might require immediate action to prevent aspiration of blood into the lungs. These kids were in conditions that might have caused them to be unable to manage the clearing of their own airway.
We came to the hospital and lined up the cases as soon as we arrived at about 9:30 in the morning on Friday, having enjoyed a two-and-a-half hour plane ride from San Jose International Airport, courtesy of our Interplast Air Force, who had conveniently brought our team along with 18 boxes of supplies.
On this particular day, as our story unfolds, it was Saturday mid-afternoon and we were doing well, having completed some great cases, when a Mexican ambulance pulled up in front of the hospital. The attendants jumped out and efficiently brought into the hospital a fresh case on a gurney, and placed the patient on the operating table itself as we enjoyed a necessary cup of Mexican coffee laced with sugar and milk in the other room. Having completed their duty, the attendants had felt free to depart. I pushed aside the cobweb forming in my somnolescent brain as my subconscious automatically said, “Don, new patient, new patient!” which translated to responsibility to assess, to consider alternatives, and to make a decision, please. As usual, I asked our best resident Ron Gruber and superb anesthesiologist Ron Atkinson from UCSD to check out the “Deets.” We found a girl, obviously American and “cauc” who had been involved in an “MVA car versus ped” – jargon for a motor vehicle accident. She had been crossing the highway after attending Bible camp, and was struck in a hit-and-run situation.
Quick assessment found a conscious girl, fourteen years of age, bp 90/60, pulse 125 with probably depressed skull fracture, fractured ribs and pelvis, ruptured spleen, and ruptured bladder—she was obviously bleeding internally.
The blood bank was situated in a little building just outside the window. We called for blood. Stat. We saw them rush out and start looking through the microscope. On initial typing we found she was AB-positive, a rare type indeed, so we asked them to not type and cross-match the blood, but to immediately bring three units of O-negative (universal donor). We obtained two units and gave them to her through two parallel IVs. We saw that her hematocrit, starting at 29, had decreased to 27 during the process of transfusion. And 0h, oh, that was all the blood that was available.
We asked them to call every hospital in Mexicali. But there was still no AB-positive. We asked them to call into El Centro in the United States, where they had a larger blood bank. They found four more units, and that was the end of the road. So we asked our hospital to go on television and ask for emergency blood donations from the 400,000 residents of Mexicali. This they did, but the patient was running out of time.
We called the chief of surgery at the Mexicali hospital, a wonderful Dr. Martinez, who quickly arrived. He was a thin, small man with a fine mustache, a serious look, and a friendly smile. We didn’t know how to assess his skills then, but I must say he was extremely competent. With the assistance of our best residents, we formed a de facto team. Dr. Martinez operated forthwith, exploring the abdomen, expertly and efficiently suturing the liver, removing the spleen, suturing the bladder, inserting a suprapubic catheter, and doing it all extremely well.
We were enjoying the anesthesia expertise of Herb McClung, 6’8” tall, at least 280 lbs, a fine American recently returned from Vietnam where he was anesthesiologist on multiple trauma cases, especially the massive amputating injuries resulting from land mine explosions. He was accustomed to administering as many as 42 units of blood during surgery and in resuscitation. The oxygen tank was located in the operating room and nowhere else in the hospital. McClung could not remove the patient from the operating table without her deteriorating to lower blood pressure. He turned to me and said, “We need blood!” I replied, “We have no more.” He said, “If this girl does not get blood now, she will die. Her death will be your fault. You must get blood. Now!” He was pointing his index finger at me and looking directly into the back of my eyes. When someone points like that, I get the shivers.
At that point Dr. Martinez was no longer in attendance. The girl, slightly conscious when the operation started, was now unconscious. Her hematocrit went from 26 to 22 during the surgery, and her blood would desaturate further each time we tried to place her on a gurney to move her to a room.
With the pointing index finger in my mind’s eye, I turned to the members of the team. I asked them each to donate one small tube of blood. The blood was quickly typed and we found that myself, Eva Hoegh (a nurse from Iceland and a chief at Stanford on our team) and Herb McClung had blood that was compatible with our patient’s. I was O-positive – an almost universal donor. We huddled a little bit to discuss what to do, and decided it would be Herb himself who would give a direct blood transfusion. We pushed a large davenport from the doctor’s personal resuscitation room, the coffee place, into the operating room. We positioned Herb on the Davenport, and placed a large-bore needle into his antecubital fossa and removed three units of blood from him. These 500 cc bottles were filled to the top, which means we actually removed about 650 cc times three. But Herb was a big monster of a guy and he seemed to be doing okay. We gave him plenty of orange juice, of course.
After transferring just 200 cc of blood by this direct “Pipeline” transfusion, we observed that the patient’s cheeks were pinking up. She raised her hands, and it was wonderful to see, like a Lazarus miracle. We gave her all three pints of Herb’s blood and she improved. The drains were not producing much serosanguinous fluid by now, as Dr. Martinez had done a fine job of hemostasis.
What to do with the patient? She still had a depressed skull fracture, fractured ribs, fractured pelvis, urinary diversion, and who knows what additional injuries? The fractured ribs made breathing difficult. We called the Naval base at Balboa in San Diego, where Dr. Terry Knapp had spent several years during his stint with the Navy. We told him the situation and asked for help.
The response was a helicopter, which did not simply appear by magic, as the navy pilot had to clear Mexican bureaucracy without delays in order to enter the country. They felt they had no safe place to land south of the border, so they landed in Calexico and “drove” the helicopter to Mexicali overland; they had to physically cut the border fence to bring the helicopter through. We arranged a Mexican-American ambulance for the patient. The Navy paramedics had everything ready, took over her life support, and whisked the child away. She was helicoptered to the Navy base in a very short time.
We called the next morning and learned she was doing fine. The skull fracture was raised and stabilized, the fractured ribs were taped, she was immobilized as much as possible, she was given analgesia, and was being assisted in her breathing in the ICU.
Six weeks later we saw the American girl when she walked in the door of the Mexicali Hospital like an apparition. We were so happy about this miracle that we thought of her life now as something extremely special. At the time we hadn’t even learned her name. Soon there was a newspaper article on Miss James from La Jolla, California about her recovery and her return to school.
On Monday, our hero Herb McClung had returned to reality at Kaiser Hospital in Santa Clara, California. In the operating room and in the coffee lounge, the customary place for the telling of lies, he fed his confrères and peers a story about his wonderful vacation weekend in Mexicali, “the garden spot of the world.” He said the sun is always shining, the most recent rain was perhaps three years ago, and there are wonderful hotels and complete pensiones such as the “Phil Collins Palace.” He built it up incredibly despite the fact that his experience that weekend could be called imperfect from a vacation point of view. But it was a highlight of his life and a fulfillment of his training from a psychic income point of view.
Something Herb might not have told in full to his Kaiser colleagues was what happened on the Saturday night in question. We would usually drink a spot of tequila on Saturday nights as a method to relieve tension in a high-stress job, strengthen team spirit, bring out conversation, and ease the cultural confluence of the Mexican and American members of the team. On this particular Saturday night we offered Herb a Mexican beverage while he danced triumphantly to the Northern Mexico Polka-like Norteño band. He asked what it was. We explained that it was “tequila, made from a cactus”, and he said he was too weak to have that. But we said he must drink to celebrate the miracle and also for his own good, for desert strength and to replenish his fluids. So he looked at the bottle and said, “There’s not much to this stuff. It looks weak. I can see right through it.” He took his first shot with lime, salt, and great cheering from the Mexican group, who expected him immediately to fall to the floor. He remained upright and continued to dance. Everyone in his instant fan club urged him to have another. Proclaiming that the stuff was more or less water, Herb downed eleven shots in total. He was like an oak tree, or perhaps a giant saguaro. He could handle more of that cactus juice than anyone I’d known before or since.
However, he finally began to waver back and forth and slowly fell to the concrete floor, quite safely I must say. It appeared that he might need intubation himself, so six of us dragged him up to his bed on the second floor community barracks into a cot and kept an eye on him as he slept off the alcohol along with the events of the day.
Perhaps Herbert McClung actually felt that he was going on a vacation, just as he described to his confrères upon his return that following Monday. I rather feel that he obtained tremendous psychic income in a way that Hippocrates would approve: instead of playing the role of the great hero, he made the more modest choice of telling a facetious little story. He must have been content with the knowledge that we had honored the guidelines that Hippocrates gave us physicians that Saturday. We had honored our oath not to abandon a patient when he or she needs help and no other resource is there. This was our obligation, and we could not simply turn the patient over to another person as if it was not our “shift.” The good feeling we all had the next day came from the joy of being a professional in our fields. I am proud that, without being conscious of it at the time, I may have shown some good example by staying with the patient and extending 110%, more than what was simply okay on her behalf. There was no such thing as “my shift is over.” Many of us, of course, discuss such matters at times in bars, in airports, while traveling, at cocktail parties, in Interplast rendezvous or in “one-upsmanship” types of conversation, the equivalent of college bull sessions. Herb, however, probably had everything together in a better way than any of us. He had chosen the greater route by foregoing the telling of the dramatic story and finding all the satisfaction he needed in knowing that he had fulfilled his Hippocratic responsibilities.
It was an adventure on many levels, and none of us will ever forget the rescue of the American girl in Mexicali. We were unfulfilled in regard to achieving our perfect vision of the spreading of plastic surgery developments to the Third World, yet more than fulfilled with the intervention and substitution of another beautiful purpose. We realized that we had just then sung another chorus in the “rule of paradoxes:” that every crisis is actually an opportunity, that there is good in every bad, that growth occurs in unexpected quarters, and that God arranges all the circumstances. It is up to us to execute, to direct free will to the left or to the right, for good or for bad.
We had been sitting there in the coffee lounge of that little old frame building that had been converted into a hospital, absolutely convinced that our goal was helping other people in foreign lands and feeling content that everything was going according to the prearranged schedule. But just when we were absolutely sure that the course was set correctly, the opposite occurred, causing temporary dysphoria but bringing about a greater and better purpose.
40 years later, it dawns on me as I write these paragraphs that the story of the American girl’s rescue in Mexicali was not about the American girl at all. It was about the adventure, the emotional high, and the pleasure of it all. That was the way we learned. The story is about myself and about Herb McClung, and how our lives were changed the moment the girl appeared at that hospital. It was true experiential learning: learning by respecting the rule of paradoxes and knowing that you are not always that boss. You make the decisions only after you are handed the circumstances.
In writing these blog stories and especially writing about the American girl and all the surrounding actions and interactions, in retrospect I have a feeling, an emotion stronger than an intellectual concept, stronger than a spiritual belief system, stronger than a physical rejuvenation. The emotion is strong as to be near to tears of joy: I now love the ambience here and actually anywhere. I love the whole world.
Addendum: June 22nd, 2011
Even hard-bitten veterans are susceptible, and Interplast’s modus operandi, which developed thoughtfully and consciously, was to adopt the theme “Go with second-class accommodations and do first-class surgery.”
We had noticed that first-class, the so-called five-star system for room and board, had bothered more than a few co-workers who were attracted to do Interplast work. It had been verbalized that for the price paid for the comfort and pleasure of the participants, perhaps another sixty children might have received the gift of life, to become transformed to a “person.” In order to fulfill the desire to help as much as possible, the second-class approach regarding expenditures on the volunteers themselves was actually welcomed by most. In the most cost-conscious attitude, we sought room and board in the homes of nice people in the community.
It turned out that the nice people lived in nice homes, and they had plenty of servants for cooking, laundry and bottle-washing. These host family members were a source of intelligent cross-cultural stimulation. Whatever the team members discussed at the dinner table or after meals in the living room or at social activities – the subjects of business matters, professional “angles,” sports, education, and cultural aspects were interchanged.
So in effect, we ended up in five-and-a-half star personal accommodations; some even went so far as to exchange their children and servants over the summer. Some wrote scientific articles in collaboration with our hosts, as co-authors. This was the rich relationship that started with a parsimonious approach. Development of the pleasurable room and board in personal residences of community leaders was given to us as a gift from the leaders of the community, as a reciprocal act commensurate with our giving first class surgery to the citizens of their community.
But don’t get me wrong. Mexicali was only in the first stage of this progressive scenario of second-class-becoming-first-class accommodations. Mexicali’s accommodations could hardly be thought to be much more than one and a half stars. We were in the private home of the project developer and community development leader, a sort of layman Christian devoting his life to good work. The house was made wit thin drywall partitions. The concrete floor was the most developed part of his house. He had a bathroom on the second floor as well as on the ground floor. Up the stairs on the second floor was a large two-room dormitory, each accommodating ten sleeping team members; one room for males, one for females. Double bunk beds were the setup. There was a table downstairs for meals, another table for playing pool, another table for ping-pong. There were chairs along the walls. The room was used for social activity after the day’s work, including a mariachi band that livened things up and promoted dancing.
I thought that some degree of adventure experienced together would bind the group into a unit more effectively, just as in war. Battle mates often become lifelong fast friends, and a bit of suffering actually does assuage whatever guilt remains in us. Furthermore, accomplishing the impossible is great for the self-esteem and body image, and it builds self-confidence.