October 3, 1963. I glance at the clinic schedule, and I see a heaven of good cases. Good cases are the equivalent of locating a treasure such as finding the Holy Grail. In the retrospectoscopic view, good cases have always been my main goal, and once having found them, they are a source of joy and satisfaction. Having good cases means to me that I am enjoying a superior surgical experience compared to peers at other universities or those poor bastards who have already entered private practice, slogging around with ordinary cases, whereas being at Stanford University, where there is wide referral from the state of California and the rest of the U.S., I have the opportunity to work on the very toughest and therefore the best cases. In my mind, I feel therefore that I will be the best plastic surgeon.
After all, after consulting the wise men of surgery prior to the tour of the training programs offered for residency and internship, I had questions for each visit to each institution, inquiring of the working resident-in-training. I would ask:
a. “Do you get good cases?”
b. “Do you actually do some surgery?”
c. “Do you have good professors for teaching?”
d. “Do they actually teach to you?”
e. “Is there an excellent library?”
f. “Do you have responsibility for patients?”
I suddenly realized that here at “Stanford, a tax-supported University,” as the Yale dean had erroneously termed our new nesting place, the answer to all six questions was a resounding “Yes!” I realized that I had made the right choice in coming to Yale and Stanford combination. I had incredible internal medicine cases. In fact, those same wise men at Marquette had advised avoiding surgery training the first years, but rather to do “medicine, where you will experience more complete responsibility and a wide variety of pathology.” But here at Stanford I had almost a surfeit of too much responsibility for a mere intern. The water was at times a little bit over my head, being handed senior-resident in medicine level cases – my schedule at Stanford included:
Paraplegia with syndrome of uncontrolled blood pressure from stimulation below the level of the lesion in the cord.
Tetraplegia and excessive potassium level during induction of anesthesia, causing cardiac arrest.
Responsibility to confront resistant infections in osteomyelitis, as intern in charge, while the others were in the operating room.
The new concept of anabolic steroids (yes) to increase muscle mass in paralyzed limbs.
Electrolyte imbalance in the bladders, which had been fabricated from the colon.
A gigantic post-obstructive urinary diuresis to 42 liters a day.
Multi-trauma after the crash of the Mighty Mouse ride at a theme park.
Ulnar nerve repair in the emergency room.
Terminal cirrhosis and acidosis.
Filet amputation of the lower limbs, with coverage of Pelvic Bones via resultant largest flap in the world.
Physiatry training from professor making rounds every day with the surgeons.
Starting a new specialty, rehabilitation surgery.
More, more. What more could you want for “good cases”?
What more could you ever desire?
This idea did resurface several times: “Boss, that cleft lip you did on Antonio Victoria was a true, instant, miraculous rehabilitation. The complex cases are rehab as well, but the process is longer term. You did that cleft lip in only ninety minutes, and the cleft palate in two hours. I wish I could try my hand at some of these cases, but we have so few here.”
In follow-up to this mini-conversation, I called Phil Collins in Mexicali to see how Antonio Victoria was doing. “Fine,” he said. “You know, there was a miraculous change in that boy. He went to school the next week, and had a girlfriend and many guy friends very quickly. He’s happy. What a change!”
The Psychic Income juices began to flow in me. I asked Phil, “Are there any more cases in Mexico? Or even in the Mexicali area?” “Hundreds!” This variety of good cases was only 614 miles from where I was reading the schedule for that week and making these wishes.
Robert A. Chase and I appeared at that spot in Mexicali within one week. Five hundred dollars was wrested from the Rehabilitation Services Administration budget; that amount covered the round trip PSA flight and a few sandwiches that we required for personal fuel.
Our first patient had a bag on his head because of a burn scar ectropion and an ear deformity. The second had a bilateral cleft palate. The third had a forme fruste cleft palate. Another had a midline cleft with a cranial vault that was completely translucent; a flashlight could shine through it in a dark room. This was a case of arhinencephaly, and was followed by someone with an axillary (armpit) burn scar contracture with inability to move the arm away from the torso (scar fusion of the upper arm to the chest). We also saw someone with a large basal-cell epithelioma of the nose, 2.2 cm in diameter.
“The line forms to the right, my friends!” A new era was about to begin.
We soon returned to Phil Collins and Mexicali for a more formal needs assessment and formed a collaborative model combining the personnel from the two areas, Mexicali and Stanford, into one team. We divided the tasks by the process of “task analysis.” We wrote a convenio, a letter of intention, set a date for implementation, and thought about rehabilitation at a later time.
We “knew” that cleft lip and palate repair was the best thing in the world, but it was only a part of the field of plastic and reconstructive surgery, which was actually then appearing to us as the way to save the world and the magic to solve all problems we had in front of us. Plastic and reconstructive surgery was able to be the key to financial independence, how to obtain freedom from the three bosses (dean, banker, and CEO) in academia, private practice, or working for a clinic or company. But it was not good enough to escape trial lawyer field, which was attempting to extract the wealth from the surgery field, transferring it to the field of the lawyers.
We learned on that needs assessment trip that the cleft lip and palate patients were not operated on in Mexicali. The more affluent patients were seen by Fernando Ortiz Monasterio or Guerrero Santos in Mexico City or Guadalajara. The poor were sent nowhere or elsewhere.
Our convenio, signed in Mexicali, stated that we would do on-the-job-training (OJT), bring all equipment and supplies, antibiotics, medicines, gowns, drapes, gloves, anesthesia medications. We would provide an anesthesiologist on our team from Stanford, as well as a speech therapist, dentist, and orthodontist. Implementation would be done at their bidding. We had formed a complete team equivalent to those personnel who are on the U.S. federal program of help for the cleft lip and palate patient set up during the depression years. We had a complete and promising counterpart model for our target patients.
The people we worked with, signing the convenio, were LAMP (Latin American Mission Program), the governor of the state, the Rotary Club, and us, Interplast. We had a treaty with Fernando Ortiz Monasterio that we could work in the area of Mexico north of Navajoa, Sonora, Mexico.
Residents were easy to recruit, as were nurses, OR staff, and postoperative recovery room staff. We almost had to shy away from people we passed in the halls at Stanford because volunteers were so numerous.
HURDLES ON THE RISE:
And then we heard, loud and clear, “Doctor, you don’t know the language.” “Doctor, do you have professional approval from the Mexican doctors?” “Their medical system, you know, includes universal health care.” “There is a huge cultural separation between you and the patient in the area where you’re proposing to work.” “How do you plan for long-term succession?” “Does your program have economic legs?” “How will the selection of patients be done?” “How will your selection of volunteers ensure quality?” “How can you keep things sterile down in that area of dust and dirt and animals?” “The logistics are impossible. Where will you get equipment and supplies?” “Doctor, don’t you know that the American College of Surgeons (ACS) forbids itinerant surgery at different sites? There must be tight follow-up. The ACS says you must be on hand to treat complications.” “You must be invited by the other country or another medical system to go there, don’t you think?” “Are there Rotary Clubs helping? Are there social workers?” “The surgical turf may not belong to you. It may belong to ENT or oral surgery.”
Post-operative care was met with follow-up by expert local surgeons, and one of us (USA) remained on site: the physician assistant Cornelis Kees Ploeg would stay there on site for two weeks. We would apply to the Colegio Medico and the governor of the state for approval. The Rotary Clubs on both sides of the border supported us and provided volunteers. The hospital was arranged by Phil Collins. Dr. Miguel Angel Rolón and Dr. Garza Canales were our sponsors.
The ACS rules all revolved around the retail trade of surgery, rather than any humanitarian aspect. e eliminated the monetary discussion from the table because we found that money always formed a nidus, bringing on heavy discussion and bickering. However, the question of whether we were down there to make money was not under suspicion, as it later would be in Honduras.
We worked on our Plan A, then formed Plan B, and then Plan C, but more than that, we worked to make Plan A so tight that we would never have to get into Plan B or Plan C.
We followed our working axiom- if you know that you are right, being out of the box is okay and encouraged. However, make sure your feet remain in the box, solidly attached to a professional friend and your institution. This guarantees you backup when they begin to take their potshots at you and your new program.
In Mexico, we found full support from local service clubs and the professional association. At the state level, the governor and his wife sponsored us. At the federal level, we had not obtained clearance, but had good connections.
On the other side, in the U.S., I had very good standing and reputation. However, national review would prove troublesome later. While the suffering of children and medicine itself know no political boundary, nevertheless in this industry, politics is a game to be respected.
We also visited the local university and formed an alliance in speech therapy. Granted, we were not able to develop a bond with the surgery department there as it did not exist. We acknowledge that was a hole
So we had a clear sense of both our goals and our objectives, measured with money, time, and numbers, were undoubtedly fluid. We were willing to alter them along the course. However, our mission statement and goals – to provide adequate care to our patients – were immutable and not open to change.
In fact, the three C’s, to change, to commit, and to control, were extremely important.
We learned the language, and with the language we learned cultural subtleties. Never say “What time is it?” Say: “How are you…what time is it?” Always consider the person before the thing. Always say yes, never say no. Ask about the person’s health, then about the family, then about the uncle in Los Moches. Stand 8 or 10 inches closer to the person in Mexico than you would in the U.S. Hugs and kisses are much more frequent. Hospitality is extremely important. If you can speak one or two words of Spanish the response is always, “You speak Spanish! Thank you.”
The geographic separation was solved with a Dodge van that had air-horns mounted on the roof and 2 extra gas tanks installed below. We identified retired pilots from commercial airlines, each having 22,000 hours of multi-engine certification. We learned that retired pilots love to fly on pro bono missions. Combine that with a good purpose and you can’t keep the experienced pilots away. In essence, our immediate plan was to solve the geographical separation with our Interplast Army and Air Force.
A DC3 purchase came shortly thereafter, but that’s part of another story, which includes the unscheduled landing of the DC3 at Marfa, Texas; the FAA inspector himself flying proper inspection. A cylinder replacement was necessary in Vera Cruz and Cuatzacualco. The DC3 brought our group together because we were in both physical proximity and very tight purpose. This resulted in good and bad outcomes – we had both marriages and divorces on site. In keeping track of them, I discontinued that research endeavor at 15 each.