Daily Herald

February 1, 1998

She is No. 75. The sun has used all the morning hours to preheat the hospital waiting room. Elba Garcia wipes her face with a white handkerchief as the afternoon ticks away.

A slight divot on her upper lip is the only suggestion as to why the 17-year-old would wait since sunrise with 74 Guatemalan children in front of her and dozens more behind. All lined up along the walls; all focused on one room.

Elba was born with a cleft lip and palate. Doctors closed the cleft lip when she was 3. Fourteen years later, Elba still bears a gap inside her mouth wide enough to swallow her self-esteem, her speech and any food she eats. She still endures an open palate that most children in the United Stated have closed before they reach the age of 1.

Dr. Blayne Hirsche, two anesthesiologist, several nurses and assistants from Utah County spend hours examining deformed mouths, burn scars that draw faces downward, feet with too many toes, and hands with too few fingers. Hirsche, a plastic surgeon, is deciding which children have the most serious deformities, and who he will be able to help in just five days of surgeries. This is his fifth visit to Guatemala to provide the children free medical assistance they otherwise couldn’t afford.

If at all possible, those seeking Hirsche’s help are asked to give some amount of money to help with hospital costs. Saraluz Capriel, Elba’s cousin who brought her to the screening paid 150 quetzales (about $25). It took the college student two weeks to earn the money.

All Capriel wants in exchange is for Elba to enjoy learning again. She went to school until first grade and never returned.

“When she was going to school, everybody would laugh about her condition, even her teacher,” Capriel says. “She just didn’t go back.”

Now, the village teenager walks a meal to her father who farms in the fields – two hours out and two hours back – every day.

Hirsche and his medical team start examining the children just shy of 11 a.m. Jan. 11.

Elba and the others had beat him there. She and Capriel had been waiting at Hospital Regional Arana Barros since 7:15 a.m. Capriel says she heard about Hirsche’s services last year when he was finishing up the surgeries. This year, Capriel says, they weren’t going to miss the Provo doctor’s visit, which was announced on radio stations in advance of his arrival.

Elba’s trek to the medical Mecca that Sunday is rewarded with a cleft palate surgery. Unfortunately, even with 10 surgeries a day during a week’s time, many children with severe deformities cannot be treated. Hirsche has only enough time to operate on half the children who come to him. Some parents approach the doctors after the screening, wondering why their long wait has not paid off.

“They almost begged us to do surgeries,” says Marie Elena McRae, a registered nurse working with Hirsche. “We turned away at least 10 to 12 people who needed surgeries.”

“It’s never been this hard to figure out.”

Each year Hirsche has to deal with the shortness of time.

“You’d like to work 24 hours straight, but it’s physically impossible,” he says.

“It’s going to be all that we can possibly do.”

All week, Hirsche fits in more surgeries than scheduled. Ten surgeries a day turns into 11. Twelve-hour days stretch longer until Hirsche finished that day’s docket.

“If I could only work faster, it would be all right,” says Hirsche, moving on to another surgery.

Hirsche and his co-workers make the most out of the one operating room they are given. They turn it into two. A blue surgical sheet that stretches across the room doubles as a divider that allows one surgery to follow another with little or no down time.

Hirsche has brought two anesthesiologists along for the first time this year. While Dr. Michael Chandler is putting one patient asleep on one side of the divider, Hirsche is finishing operation on a child put under anesthesia by Dr. David Lind. Though this is not common practice in the U.S., the doctors say it makes the most of time and facilities offered to them.

Maria Andrea Ramirez, a 7-month-old, is the first cleft lip case Hirsche sees on his visit. More than a minute’s worth of anesthetic from Chandler finally puts the baby asleep and Hirsche takes a purple pen to create the design of Maria’s new lip.

“Dr. Hirsche is an artist. He’s an incredible artist,” says Jordan Graff, an anesthesia technician.

Cleft lips and palates are much more prevalent in Guatemala than in other countries, says Dr. Ludwig Ovalle, a member of the board of directors of the Pediatric Foundation of Guatemala. While the mouth deformities are often inherited, doctors think diet and other environmental factors might lead to a predominance of malformations in the central region of Guatemala, he says.

One out of every 4,000 Europeans is born with cleft lips or palates; one out of 1,000 Americans develops them. In Guatemala, Ovalle says, one in every 200 children grows up with lip and palate impairments that impede speech and allow food to enter the nasal cavity while eating.

“We will never be able to operate on all of them,” Ovalle says.

The Pediatric Foundation of Guatemala coordinates medical missions throughout the country, bringing in foreign doctors to provide medical attention that is not available or is too expensive.

Out of almost 20 missions each year, only a couple serve the Chiquimula area. Hirsche is the only plastic surgeon to visit the city, located three hours northeast of the country’s capital, Guatemala City. There are no plastic surgeons in Chiquimula and only a handful in Guatemala, says Rodolfo Rosenberg, who coordinates the medical missions.

Doctors who do cleft lip and palate surgeries in Guatemala City charge between 10,000 and 13,000 quetzales – about $2,150. Many Guatemalan families make only 600 quetzales, or $100, a month. And that’s to raise a family of six or seven, not just one child with a mouth deformity, Rosenberg says. Without Hirsche’s donation of surgeries, many of these families could not afford to help their children.

“They’ll never have an opportunity again,” he says.

Deborah Witte, an operating room nurse, cups her hands over a 10-year-old’s mouth, forming a dam to slow the blood flow. Hirsche has just finished removing a bulging cluster of blood vessels from her upper lip, and the girl begins to awake. She struggles on the operating room table and several hands hold her still. Vicki Wixom, a nurse quietly sings “I am a Child of God.” Witte strokes the girl’s dark black braid.

Her name is America. Her mother says she just liked that name.

“Ya terminamos, America. Ya terminamos,” says Graff at the young girl’s side.

We’re almost done. We’re almost done.

Martina Ixlaj and her husband, Israel Perez Chanx, wait in the recovery room for their daughter’s long-awaited surgery to be over. The thin-faced farmer stands tall in his short frame. Ixlaj talks about rejection.

The couple raises four children in a town that is a nine-hour bus ride from Chiquimula. Ixlaj noticed the growth on her child’s lip when America was only 4 months old. Doctors would refer her to other doctors, but never the right one. No clinic or physician could help.

“She says it kept growing. She felt a lot of anxiety and sadness that her beautiful daughter has a deformed lip,” says Blanca Holt, the recovery room nurse, translating for the couple.

America’s upper lip was getting heavier and more noticeable.

“She felt very sad all the time,” Ixlaj says. “She felt sad and embarrassed to go out in public.”

“She always covered her face with her arm so no one would see her,” her father says. “She loves going to school, but she hesitated to go because of making fun.”

Finally, The Pediatric Foundation told Ixlaj about Hirsche’s visit.

America and her mother stay several nights in the hospital after the surgery. The morning after her operation, Hirsche and the doctors make rounds to see how the patients from the day before are doing.

America is sprawled on a mattress covered only in plastic. Her mother sits in a lawn chair next to the bed.

Overnight accommodations for concerned parents are meager; the bare floor is often all there is.

The pediatric ward is enclosed with high walls painted with Walt Disney characters and lined with metal-framed beds and cribs colored bright blue. Pink sheets hang over the windows above eye’s view, throwing dark shadows on the remarkably quiet 40-bed facility that has few vacancies while Hirsche is there.

Upper respiratory and gastrointestinal illnesses are the most common and most deadly hospital director Hugo Ruiz. When these children get sick, there’s only one pediatrician in the hospital to care for them.

The sole maternity ward in the state of Chiquimula, housed in the same building, is just as sparse. Chiquimula, the state, has 290,000 people. Chiquimula, the state’s capital city, has about 80,000. Ruiz says the hospital delivers only about 30 percent of the births in Chiquimula; the rest are handled by midwives or no one at all.

New mothers lie on the hospital beds in the maternity ward. The newborns rest nearby, swallowed in the middle of their own oversized twin hospital bed. The infants do not have cribs. There is only one incubator.

Ruiz walks past the emergency room where a 14-year-old boy lies. Alberto’s hand is cut from side to side and the doctor is cleaning the wound. Alberto didn’t want to go to the hospital, so he tied a tourniquet around his arm and was heading back home. Blanca Dina Lemus de Camon found him bleeding on the side of the road and made him come. “I will pay any charges that they have. But you can’t go like that,” says Lemus de Camon as she waits for him in the hallway.

Ruiz says the emergency room usually sees patients injured by some sort of violence – fights with firearms or stabbings.

Hospital Regional Arana Barros is a state hospital that receives 6 million quetzals, or $1 million, to cover all of its annual costs. Malaquias Flores, a translator who helps surrounding village farm efficiently, says there is no insurance program in Guatemala, only some health benefits for state employees. The public hospitals, such as that in Chiquimula, are supposed to provide free care.

“But they don’t have anything to provide,” Flores says. The hospital ends up charging for medicines and other services.

On the other end of the hospital is the intensive care unit that has enough beds for 10 adults and five children. Directly in front of the ICU is the recovery room. Wooden posts on four-pronged stands hold up the IVs. The ICU and recovery room are open to the outside air, a concrete walkway and a sand-covered courtyard. A dog runs up and down the hallway. A man smokes inside the hospital entrance.

Through two sets of doors that stay shut is the operating room Hirsche’s team is working in.

“I’ll tell you, it looks better every time I come,” Hirsche says. “It’s not Taj Mahal, but it’s a while lot better than it was.”

Mary Witte is the mother of the operating room while Hirsche’s team is there. The registered nurse hovers over the other assistants – two are her own daughters – and makes sure the doctors have the necessary instruments when the time comes.

Witte admits that the Guatemalan nurses who have been wandering in and out of Hirsche’s operating room all week are more qualified than she is.

“These nurses that don’t have a lot of stuff to work with, I feel, are better than me,” Witte says.

Witte thinks it’s important that American physicians and nurses understand they can get by when they run out of the instruments and disposable supplies they are used to having. Witte pulls up her sleeve, revealing a scar on her arm from a camping injury.

“I sewed that back myself. Actually, I just butter-flied it back and glued it,” Witte says.

In Chiquimula’s operating room, she fashions arm splints with tongue depressors and tape. Even though she can make due and improvise when need be, her eyes dart around the room and focus on several items that would never meet American deferral regulations.

“It’s a wonderful attempt,” Witte says. “Everything is about 50 years behind, but it’s not their fault.”

The operating room is green. Green tile. Green paint on the walls. Green paint over the windows.

“That’s to help with the sun,” Wixom says. “Thank goodness it’s there.”

The equipment is much older than that used in the United States, except for one small box that stands as a dichotomy to the rest of the apparatus. Nu Skin International Inc. of Provo donated $25,000 to Chiquimula’s hospital to be used for needed equipment. Almost $8,000 went toward a new monitoring device that Lind uses during his work. Lind and Graff taught the Guatemalan doctors how to use the equipment because the machine stayed in the operating room after Hirsche’s crew left.

Lind remembers the day he discovered that the hospital’s only defibrillator, a machine that shocks the heart back into rhythm, was broken.

Midday, a Guatemalan woman who had delivered a baby that morning went into cardiac arrest. Holt, the recovery room nurse, alerted Hirsche’s team and Lind responded by giving CPR to the woman. After a series of drugs and CPR sessions, Lind and the Guatemalan doctors and nurses were able to start a rhythm and eventually get a blood pressure reading for the woman. At one point, Lind asked for the defibrillator.

“They said that their defibrillator is broken,” Lind says.

Lind says he noticed a faulty fuse in the defibrillator, but didn’t know if there was anything else wrong with the machine.

“Then they called me back in and said we’re waking your patient up and we’re about ready for you to bring the next one in,” Lind remembers.

Lind left the woman with the Guatemalan staff and returned to the operating room. When he finished and came back out, a nurse was still ventilating the woman to keep the oxygen flowing in and the carbon dioxide moving out. In the meantime, however, the woman’s heart had stopped. She died in Chiquimula’s hospital.

Lind doesn’t know whether the woman could have been saved, even with a working defibrillator. The incident, however, helped him understand a difference between reaction to death and concern for life in Guatemala and the United States.

Chandler says he thinks death is more common and visible in Chiquimula. People in the United States would have panicked while watching the woman die in Guatemala, Lind says. Those in the vicinity at the time weren’t overly concerned or amazed, however.

“In a sense, life is cheap,” Chandler says. “They don’t extend all efforts to save someone’s life.”

Lind says he had hoped the resuscitation efforts would have been successful, not for the American doctor’s sake, but for the Guatemalan doctors’. He wanted them to discover hope, to see what is possible in the medical field. And he wanted them to be the reason the woman lived, after they had worked such long hours all week learning from Hirsche and his team.