Dhaka, Bangladesh Surgical Volunteer Trip

The Tragic Burning of Sufia

  Sufia 
  Originally uploaded by interplast.

Sufia, age 17, lives in the burn unit of the Dhaka Medical College. It has been her home for the last eight months and before that she lived in the district hospital of Narail, about 150 miles north of Dhaka, for five months. She has not known any other home since she was burned.

Here is the story of how she suffered her disabling burns. The rice harvest was done. The men bundled the paddy and threw it in a high heap in the middle of the courtyard. It is the women’s job to process the plants into edible grain – get the grains off the stems, dry it, husk it in the foot pedal and store it. In addition, all the routine cooking and housework of course had to be done. Sufia was at wits end about how to cope with her two sons – the 4-year old did not need much, but the two-month-old son wanted to be breastfed every two hours.

She had a heated quarrel with her 55-year-old husband and went to bed after dinner. As it was Ramadan, she’d have to get up at 3 AM to cook the meal that they would eat before sunrise; nothing to eat is allowed, not even water, during the day.

In the middle of the night, she woke up with a start to find someone sitting on her chest holding her mouth shut. It was her husband – his brother tied her both hands over her head, another brother tied her both feet together. They dragged her off the bed to the corner of the room, poured a cold fluid that smelled like kerosene that was used to fuel the lamps, set her on fire and fled.

Sufia could not scream since her mouth was tied with a piece of rag, and could not run with both feet tied together. But help came when neighbors saw the smoke and fire from the house and started to pour water to put it out. Then they discovered Sufia.

Neighbors hired a vehicle and took her to the nearest treatment facility; they would not take her. Then the neighbors took her to the district hospital and she stayed there for five months. She did not have anyone come visit her or look after her as her parents were dead, and the neighbors lost interest after some time. Only her maternal uncles would come once in a while, but they did not have money enough for her treatment. So she would be with out medicine most of the time, but there was a roof over her head and some food.

She needed a kind-hearted soul to feed her, as both her hands were just stumps. The few fingers that were left in her right arm were so stuck to her hand she could neither move or use them. So on days when she did not find someone willing to feed her, she’d go hungry.

Sometime in March, the kind-hearted doctors transferred her to the Dhaka Medical College Burn Unit. The facilities here were so much superior to those at the district hospital. Her open wounds started to heal, and after a surgery in September, she could stick a spoon between her fingers and feed herself. Now with the Interplast team in the city, she was selected as one of the lucky ones to have the hand surgery in which the team specializes.

One thing that Sufia wants most is to be able to use her hands, to find work, to be able to support herself, and maybe see her two sons again if she is lucky. She knows nothing about them. Her uncles told her that there was no police case against her husband and his relatives, and Sufia’s uncle did not have money to bribe the police to pursue the case.

Even if the hand surgery is a phenomenal success, she will probably have about two or three functioning fingers in the right hand only. All other fingers are gone. Sufia has no home to go back to, no relatives to take care of her and no one to help her with negotiating her way in the world outside her home. She was married at 10 years of age, has no experience outside her home, never been to a bank, a market or inside any office. She had virtually no education or any skills to enable her to earn a living. So the future is frightening and unknown.

Mohammed, future social entrepeneur

Mohammed, future social entrepeneur
Originally uploaded by interplast.

Mohammed is a 12-year old boy who suffered extensive burns three years ago. He was secretly doing an experiment and hid it from his mom. He was fascinated with matches, so he stuffed several boxes (each box contains 40 matches) of matches in a plastic make-up container and went into the bathroom. He lit a match and threw it in the make-up container. The closed make-up container blew up causing burns on most of this face, chest, arms, hands and feet. The melted plastic from the make-up box and bathroom doorknob showered and stuck to him. He has had eight surgeries involving contracture releases and skin grafts. He enjoys reading books and watching movies about Harrry Potter and English is his favorite subject. He is in the 3rd grade and aspires to be a plastic surgeon. He wants to help other patients like him. He wants to treat the rich and the poor. He plans to use the money from the affluent patients to treat the poor for free.

Lost In Translation

  Patients in the Ward 
  Originally uploaded by interplast.

We lose a lot in translation. Literally. In an attempt to communicate pain level with the patients, I was teaching them “Thumbs up” and “Thumbs down” signs. It was much simpler than trying to explain the whole pain scale thing without an interpreter.

Well………… it seems that here the thumbs up sign means something like ”I don’t care about you, I can’t be bothered with you”. Whoops! Thankfully a smile is a universal symbol...

Interplast in Bangladesh

Mother and Daughter
Originally uploaded by interplast.

This mother accompanied her daughter before her operation. She was really sweet and was very grateful to all of the doctors. The patients are often too groggy after their surgery to be very appreciative, but the parents always tells us how important it is that Interplast comes to Bangladesh.

Ways Of Dealing With Tension

  Fran Relaxing 
  Originally uploaded by interplast.

After a wonderful day off in which we took a city tour, visited the ancient capital of Bangladesh, saw some countryside, and ended the day with a bout of shopping, we had our first full day of surgery using general anesthesia. Shafquat was able to procure two anesthesia monitors for us and so we started on the cases that we could not do last week. With the bombings, the strike and the stress over the boxes which still have not arrived, the team is in surprisingly good spirits. We all have found different ways to deal with the tension.

Uncommon Occurrence

Unusually Large Finger
Originally uploaded by interplast.

This little boy has an unusually large finger on his right hand. We were able to operate on the enlarged digit, and he is doing much better now. This is a pretty uncommon occurrence, so our doctors were especially attentive during the case.

Kiran

Kiran
Originally uploaded by interplast.

It has been a real treat to work with Kiran. He is taking a break here, but he is a very hard worker and very dedicated to helping poor children.

Interplast remains deeply grateful to the Syde Hurdus Charitable Foundation, which supports the Syde Hurdus Fund for Cleft Care in Nepal through Interplast. Through this Fund, the Foundation provided key supplemental funding for this trip to Dhaka, allowing Dr. Kiran Nakarmi to join the Interplast team and receive valuable medical education, all while helping to change the lives of Bangladeshi children in need of hand surgery.

Yippeee!!

  Two to a bed 
  Originally uploaded by interplast.

Yippeee!!

My supplies are here!

My luggage was lost. We arrived Sunday at 1:00 am and my luggage finally arrived Thursday but the airport security was holding my work supplies stating they needed to be taxed. So I was asked to not pick up my personal luggage until they could arrange picking up both claiming my supplies as personal as well. And it worked! One of the doctors escorted me to the airport today. He told the airport personnel that I was there to help the countries poor people so they should help me. So I have all of my supplies.

So now I can make real splints that will fit the patients and provide good support. A day of celebration. The next celebration will be when the entire team gets the supplies they need. We have all learned a lot about working with what is available, which is valuable to these people because we are working with the conditions that they face each day. Seems much more beneficial when you look at it that way.

In this photo, there are two patients in the bed. With more patients than beds, we make do with what we have.

On to Success!

  On to Success! 
  Originally uploaded by interplast.

Everyone is talking. The patients sit all around us in the recovery room. It is rounding in the true sense of the word. The surgeons review the cases and tell what they want post-op. Then the action begins. Dressings come down. Everyone helps for that. Then we’re on to cleaning the wounds. They wash in the sink with soap and water and then we redress them. Our dressings consist of Adaptic and antibiotic ointment. We have boxes of sterile 4 x 4’s which has been great. These were left from previous trips.

The locals have given us their “Kling” wrap. This is cut from bolts of very loose woven cheesecloth using the same giant scissors that I am using for the splinting. The strips of cheesecloth are then hand-rolled and autoclaved for sterilization. Quite a process.

After the wounds are redressed they get their exercise instruction. I am learning in Bengali how to say straight and hold. And I can count, too! Ak = 1, dhu = 2, tin = 3, chir = 4, and phach = 5. They seem to enjoy that I am trying to learn some of the basics of their language. Many come to me and ask me how I am in Bengali so I will respond, ”I am fine”. They always laugh so I have a feeling my pronunciation needs work.

It is a busy time for the next 2-3 hours and then things begin to settle down. They are all patient and wait their turn watching each other and encouraging each other along. And when one of them gets his finger all of the way down they hold it up so others can see, proud that they can move. On to success!

Another Suicide Bomber

Another suicide bomber today, this time in a government building housing policemen. I'm not sure of the total number of dead, but 11 victims were brought to the hospital where we are working. When we left the hospital late this afternoon, the police were everywhere and the atmosphere definitely very tense.

On a brighter note, it looks like we are finally going to get our boxes. At least that was the news when we left the hospital. Shafquat should be able to confirm this tonight at dinner. We did some incredible cases today under local anesthesia.

Teething Time

Little Mim is a 6-month-old girl born with arthrogryposis. Her thumbs are folded into her palm. Her fingers are flexed with the wrist bent down. Her elbows are flexed as well. I was fitting her to splints to hold the wrist/fingers/thumb/elbow into a better position while sleeping. She had the biggest smile and huge round eyes. Every time I tried to put the splint material on her arm, Mim would lean down wanting to have a finger in her mouth to chew on. She is just starting to teeth and she was wanting to chomp down with her little gums. It was making splinting a bit difficult. Every time I reached toward her, her mouth opened. I finally had to ask the mother to hold her finger in Mim's mouth so I could have my two hands to work.

Box Saga Continues

We are hoping to get the supply boxes today. What a hassle, but we have been able to operate by stringing many things together. But now supplies are very low. There also is a general strike today because of the suicide bombing, so no vehicles are allowed to run and it is too dangerous to be out on the street.

Susie Scissor Hand

  Susie Scissor Hand 
  Originally uploaded by interplast.

Splinting material is a low temperature plastic that must be heated in hot water to make it pliable. It is then molded to a person’s hand to protect it after surgery, immobilize joints or with elastics pulley systems to improve motion. So we pack up our fry pans, Velcro, splinting material and off we go. Except when the supplies don’t arrive…

Shafquat came to the rescue. Previous Interplast trips had left supplies, so he had them brought up to the recovery room where I set up. It is a very big room that the patients are being blocked (anesthesia) as well as recovering post-op. Shafquat sent up a sterilizer with hot water for me to use. There is no temperature setting so the water is just about boiling. It is much hotter than it should be for the splinting material so I do quick dips to try to control it. Then came the scissors……12 inch monsters that chew through the material at best. They are a bit daunting to say the least, and I am now called “Susie Scissor Hand”.

Heartwarming and Devastating

The people are so beautiful. Their smiling faces and horrific injuries are heartwarming and devastating all at the same time. They are all so grateful for our care and treatment. The hospital is much larger and more advanced than I had expected. The wards are crowded, but the halls are clean. Conditions are however, primitive by our standards. They manage to maintain a vigorous surgical schedule with general anesthesia and no monitoring equipment of any kind. Old fashioned observation is their strongest tool. The doctors and residents are most anxious to help and learn.

Colorful, Exotic and Fragrant

So many people....People everywhere. People in cars. People in put-puts. People on foot. People in rickshaws. I have never seen so many people in one place. Everywhere is crowded.

A camera of any type can’t begin to describe capture the experience. The sounds of the cars. The voices. The food . The smells. A virtual sensory overload of the most wonderful kind. I have been told that the population density is 1400 people per square kilometer, more dense than Tokyo. At times, it seems so much more.

Traffic is horrific at times. A suicidal cacophony of pedestrians, bicycles, rickshaws and automobiles. We have enjoyed beautiful early morning rickshaw rides to the hospital. The streets are filled with vendors of all types. Colorful, exotic,and fragrant mixtures of flowers of all varieties. The foods are amazing in their aroma and presentation [not always appetizing ]. 

The food we have eaten has been fabulous. I can neither describe or pronounce most of it, but have had no problem with consuming. I am however looking forward to pizza tonight.

Never Miss an Opportunity to Educate

The first patient was a burn victim. Her hands were severely contracted so, she was fitted to a dynamic MP flexion splint. Her husband is a physical therapist. I asked if he helped her with range of motion exercises. He answered yes and that he used ultra sound which he was very proud of. So I took the opportunity to briefly instruct him on stretching her hands using the splinting concept of slow and gentle prolonged stretch and the importance to prevent further contractures. Never miss an opportunity to educate.

Bangladesh’s First Suicide Bomber

About mid-afternoon, two patients were wheeled in on gurneys—it was obvious that it was emergency care. The male patient kept screaming.  The female patient arrived in terrible condition—her legs had been blown off. We had briefly heard that there had been a suicide bomber who had blown himself up inside a courtroom in a town on the outskirts of Dhaka. It turns out that there was another bombing in another province. We soon learned that the two patients in the OR’s adjoining ours came from the bombing. One of them was the bomber himself.

When I exited the OR area, I found several police officers with machine guns standing at the entrance. They were everywhere in the hospital.

First Day of Surgery

The first day of surgery appeared to go fairly smoothly. With 15 people who had never worked together and who had to make due with what supplies we had, it was quite a successful day.

I spent the afternoon in Shafquat’s office helping him rearrange the packing lists that Jim had sent to us electronically. The computer had a virus and was working very slowly—sometimes it even wiped out everything we had done and failed to save. I was ready to throw it at the wall, but Shafquat was his usual, calm self, and put me to shame for my flare-ups. We laughed about it. 

Shafquat’s residents have been wonderful this year. He has four dynamic women who are among his registrars, and they are incredibly efficient and helpful. They have forced the males to be involved. A few minutes ago I passed by the lounge—four men were in there sipping tea. All the women were scrubbed in on cases. But I think that they are all excited about working with Tony and Kiran and they are asking lots of questions. This morning a young anesthesiologist walked in and he was brought immediately to the OR so that he could start learning about blocks.

Rashida

  Susan Wong and Rashida 
  Originally uploaded by interplast.

At the moment, I’m sitting in the post-anesthesia care unit (PACU) and the PACU nurses are giving an IV to one of our female patients who is about to have an operation. Her name is Rashida. She has just told us that she has her hand injury because she broke a picture frame and her husband beat her with a bamboo cane. She was crying earlier from joy and told us that she would pray for us because our medical volunteers are caring for her. Rashida also just offered to give us her 11 year-old son to adopt so that he could have a better life. Carrie, recovery nurse, is sitting next to me crying quietly — the depth of Rashida’s suffering was too much for Carrie who is also a mother. She had to move away from the bed so that Rashida would not see her tears.

First Surgery Day

This morning we were all excited because we were finally going to begin surgery. After we set up the OR (Interplast Australia, who we have no affiliation with, had left some supplies and Shafquat located some supplies he had from a previous Interplast US trip), we all gathered in the OR with the local nurses and Shafquat’s residents. After Jon took the team through the emergency scenarios (what to do in case of a number of different emergency situations), Tony addressed the residents. He explained that one of them would be assigned to each patient, and they would be asked to present each case and eventually perform surgeries. They seemed eager to participate. What a great learning experience for them! There are four women residents this year.

What To Do Without Supplies

We had a team meeting to strategize about what we would need to perform surgery without the supplies that were stuck in customs. Tony estimated that he had about 20 cases that would only require local anesthesia; we could do about 10 of them the next day if the boxes did not show up. Shafquat joined us and each specialty asked him about the availability of certain supplies that were essential. Those items that he did not have, he made arrangements to purchase. Luckily, many team members had brought items in their personal luggage and everyone felt comfortable about going ahead with the planned scheduling of cases. We left Tony, Kiran and Dr. Jon Hooper, volunteer anesthesia chief, at the hospital to sketch out a schedule for the next two weeks. We grabbed taxis this time for transportation back to the hotel—about $1.50 a ride.

Clinic

Monday we woke up early, eager to begin clinic. This was held in Shafquat’s office. Tony and Kiran spent a lot of time examining the patients with the local residents. Shafquat had pre-screened more than 110 patients and we had a list of all those who would be coming that day. Tony and Kiran accepted 70 for surgery. Many of the other patients were referred to Susie, our hand therapist, for treatment instead of surgery. The room was very crowded, but all of us were so interested in seeing the patients and participating in the clinic. Because our boxes were blocked at the airport, the whole team was able to participate in clinic—something that is rare on an Interplast trip. Usually many of the volunteers are busy setting up the operating rooms and the recovery room while clinic is being held and they are unable to participate for any length of time.

Shafquat was not able to obtain a hemocue for the pediatrician, so they devised a plan to have only those who she was a bit worried about sent to the lab for a hemoglobin test. Otherwise we didn’t really suffer from the lack of equipment and supplies. The day was long and the team was tired. All day we anxiously awaited news of our boxes. The team remained optimistic and kept saying they were sure that we would get them in the afternoon. By the end of the day, with little good news about the supplies, the team seemed a bit on edge.

"Sheraton"

  Bangladesh Transportation 
  Originally uploaded by interplast.

We had so much fun riding the rickshaws to the hospital earlier in the day, we all hopped on the rickshaws accumulated on the hospital grounds. Fran Fisher, the head nurse, and I shared a seat. We realized after awhile that none of our fellow teammates were anywhere to be seen, but there was so much traffic that we weren’t unduly alarmed. Our poor rickshaw driver had a bicycle that was obviously a bit worse for wear and it was clear that we were quite a burden to carry. More modern rickshaws kept whizzing past us. At times, our poor driver was forced to get off the bike and push it. As the minutes ticked past, we began to wonder where we were. The street scenes were quite unfamiliar, but we figured that he probably knew a shortcut. Just in case, we began to repeat “Sheraton Hotel”; each time he nodded, smiled and repeated “Sheraton.”

Suddenly we were in the middle of a market. Animals for sale in cages, clothes, fruit and vegetables, fish and poultry. And the traffic became especially heavy—we experienced quite a few near misses with taxis and other rickshaws. Fran and I finally figured that we were quite lost. We once again emphatically repeated Sheraton Hotel. The passenger in the rickshaw next to us seemed to understand what we were saying and said something to our driver. He appeared puzzled. Luckily a policeman was on the corner and he asked him for directions. We were off course by quite a few streets and the policeman stopped traffic so that our driver could find his way back. Fran and I had a great adventure, but unfortunately, the rest of the team was in quite a panic when we didn’t turn up at the hotel. They were back within 10 minutes. It took us an hour. We decided at that point that each volunteer would always carry the name of the hotel in Bengali. As in many Asian cultures, it is impolite to say "no" or "I don’t know" in Bangladesh.

Seeing Patients

Plastic surgeons Tony and Kirin started examining about seven patients that Shafquat had arranged for them to see and it was a super teaching experience for all the residents. The rest of us were taken on a tour of the hospital facilities. We began to talk about what we would do for clinic without any of our secretarial supplies and equipment for examining the patients. Luckily we now send the intake forms ahead of time to the trip coordinators, so we had those sheets along with the wrist bands. We left the hospital at around 5:30, tired but satisfied that the next day we would be able to at least hold clinic, where we evaluate patients and create a surgical schedule.

First Day in Dhaka

I decided that we wouldn’t use the buses as Shafquat told me that it would cost us $70 a day. I thought that would be a hefty price to pay for a two mile trip back and forth to the hospital. We decided to walk as it was so nice outside and the route is rather beautiful. Once off the main road, we found some bike rickshaws and decided to hop in (two at a time) for the rest of the way to the hospital. It was a fun experience for all of us. The price was around 25 cents (US) for each rickshaw.

Once at the hospital, we went directly to Shafquat’s office. He had chairs arranged for us and we introduced him to the group. He had sent Dr. Shankar Man Rai (our surgical outreach director from Nepal in Dhaka for further training) and another registrar to the airport to see if they had any luck with the boxes, while he worked on the phone at his end.

Box Saga Continues

Shafquat is now producing document after document again and it is slowly making its way through the governmental offices so we can bring our equipment and supplies in tax-free. Yesterday he believed that we had a 70 percent chance of getting the boxes before the end of the day, but at 5 pm he came to see me with the bad news that yet again he must produce another document. The news was a definite downer for the team.

Customs

As the happy group made its way toward the exit, a customs official stepped forward and started to quiz us about our boxes. I pulled out our letter of invitation from the Bangladesh Ministry of Health as our international partner Dr. Shafquat Khundkar had asked us to do. The customs official was interested in our countries of origin and began to ask us many questions. I saw Shafquat outside waiting for us and I gestured to him that all was not going as planned with customs. Somehow he was able to enter the customs area and then began the long discussions with the customs official.

In the end, the customs official was insisting that we did not have all the proper papers for bringing in our equipment and supplies “tax free” and so he was not going to release anything until we either produced the proper documents or they went through every item in the boxes to levy a tax.  This was the first time in 15 years Interplast has had a problem in customs with our boxes.

At this point, the team was sagging and it was very late. We had to leave the boxes at the airport until everything could be straightened out. Every box had to be inscribed by hand into a notebook with a description of its contents. Luckily we had the box list that we gave them. Shafquat told me that there was nothing else we could do and suggested that if Dr. Tony Sudekum remained with him to sign the document the rest of us should leave for the hotel. I was only too relieved to finally be able to take the team to bed. They were exhausted, and by the time we arrived at the hotel and sorted out the rooms it was 4 am. Tony came in about 4:30am. I asked everyone to meet at 11 am for our team meeting, after which we would have lunch and then head over to the hospital to meet with Shafquat and his registrars.

Arrival

Just before 1 a.m., our plane touched down at the Dhaka airport. Most of the Interplast surgical team had met up in Hong Kong, converging from the U.S.’s West Coast and East Coast and Canada. Two of the team members were already in Dhaka—Dr. Ayesha Ali, the anesthesiologist born in Bangladesh now residing in Great Britain, and Dr. Kiran Nakarmi, our hand surgeon from Nepal.

We were tired but relieved to find that all our boxes and equipment had arrived. Unfortunately, Susie (hand therapist from South Carolina) could not find her luggage or her box of supplies which had somehow been left behind at her plane change in Chicago. She is still living on the few bits of clothes that she had brought with her and will go out today to buy a few essentials to fill the gap until her luggage arrives.

Introduction

Hi.  I'm Beverly Kent, director of volunteer services at Interplast.  I am currently on an Interplast surgical volunteer trip in Dhaka, Bangladesh.  Over the next two weeks, our team of plastic surgeons, anesthesiologists, nurses and coordinator/translators will be providing free reconstructive surgery to Bangladeshi children.  I hope you check this blog frequently to find out how we are doing and who we are helping!