More Than Smiles

More Than Smiles

Editor’s Note: In Ethiopia, Operation Smile is helping to strengthen the country’s health system through specialised training and education programmes while continuing to provide patients with world-class levels of surgical care. This story is the first of a four-part series.

A little girl is lying on a hospital bed in a ward corridor. Her mother is covering her face, trying to protect her from people’s curious gazes. The skin on her face, chest and arms is terribly burned and she can’t close her eyelids. She needs surgery as soon as possible to preserve her eyesight. But at the hospital, which serves more than 15 million people in southwestern Ethiopia, there are no plastic surgeons that can help her.

“She was playing with her friends at home where they had an open fire on the floor. By mistake, her friends pushed her, and she fell face down in the fire,” Dr. Yonas Metaferia says.

A general surgeon at Jimma University Specialized Hospital, Metaferia is participating in Operation Smile’s Surgical Training Rotations, which occur twice annually. Per Hall, a British plastic surgeon and Operation Smile volunteer, has been coming to Jimma regularly since 2012 to train general surgeons in reconstructive plastic surgery techniques and theory.

“Oh dear, this is a surgical emergency,” Hall says when he takes a look at the girl with the burn.

Unfortunately, the girl is too dehydrated to go through surgery immediately. The team decides to have her transferred to the plastic surgery unit at Addis Ababa to receive surgery as soon as possible to save her eyesight.

“It is actually very upsetting, isn’t it, that you have cases like this without instant access to plastic surgery,” Hall says.

“Originally the hospital thought they just wanted us to come and do cleft lip and cleft palate surgery, which is what Operation Smile was about originally. As we came back over the years, they’ve realised that plastic surgery isn’t just about smiles – it’s about reconstruction,” Hall says as he follows Metafaria in his rounds at the general ward.

“They realised there was so much more we could offer with various types of plastic surgery techniques. We could help them with reconstructive surgery after removing cancerous tumours, with reconstructive burn surgery, with injuries to the hands by machetes or knives and with all these people that are hit by cars or fall off trees and have nasty injuries in their legs or limbs, exposing bones. You need to cover the wounds with skin – and that is plastic surgery,” Hall adds.

One of the patients who needs reconstructive plastic surgery is Meheftehe, a 1-year-old girl born with a severe facial cleft that runs from the corner of her eye down through her cheek and into her mouth and plate.

“As we came back here over the years, they’ve realised that plastic surgery isn’t just about smiles – it’s about reconstruction” – Per Hall

Meheftehe’s mother brought her to the hospital when she was only 19 days old, covering her face completely and afraid to show her to strangers, believing they would judge her for her daughter’s deformity.

At that time, the baby was too small to receive a safe surgery. On a surgical mission to Addis Ababa a year later, Operation Smile’s team performed the initial surgery to save her eyesight.

Now, Meheftehe is back for her palate surgery. This time, her parents are not hiding their little girl. They’re happy to show her to the world and let her make new friends at the hospital waiting room.

“I am 100 percent satisfied. You cannot compare before and after her first surgery. For each month, there is an improvement,” says Genet, Meheftehe’s mother.

Meheftehe will need many more surgeries to fix her facial cleft, including a bone graft.

However, in a country of almost 100 million people, the lack of plastic surgeons makes reconstructive surgery impossible for most. Today, there are little more than a dozen plastic surgeons, and almost all of them are based in Addis Ababa, the capital city. In Jimma, the need for plastic surgeons is immense, as it is across Ethiopia.

In 2012, Operation Smile began funding surgical training programmes with the goal of establishing a plastic surgery unit at Jimma University Specialized Hospital. Two of the hospital’s general surgeons are now training at plastic surgery units in Taiwan to become plastic surgeons, as part of a three-year curriculum required by the government. They will later return to Jimma to start the plastic surgery unit at the hospital and continue training new plastic surgeons in their home country.

Meanwhile, Hall and his fellow Operation Smile volunteers return to Jimma twice a year to help Metaferia and his colleagues as much as possible.

The focus of the two-week Surgical Training Rotations are to teach best practices and techniques not only to surgeons, but to anaesthetists and nurses as well.

Metaferia, the next surgeon to take part in the three-year curriculum and will train abroad in South Africa, performs a cleft lip surgery under the supervision of Hall. The result is excellent, and Hall is very optimistic about the future.

“In three years time, this will be a very vibrant, exciting new service. They will have their own plastic surgery ward and their own plastic surgery theatres,” Hall says. “They are going to come back with new skills and new techniques which will be new for this part of Ethiopia, certainly. Some of their skills will actually be new for Ethiopia in general.”

Meet Dr Rebecca Wilde

Rebecca is a UK-based anaesthetist, who participated in the Operation Smile Regan Fellowship Programme. She volunteered on medical missions in Ghana and Malawi.

Rebecca with a patient in Malawi

What inspired you to first get involved with Operation Smile?

‘I was inspired to get involved with Operation Smile by a colleague who was an amazing advocate for the charity. He then mentored me as a Regan Fellow in 2016, which was a fabulous experience that allowed me to witness the work Operation Smile does in the field. I committed to being a volunteer once I met the founders Bill & Kathy Magee and heard them speak about their 35 years of involvement since starting the organisation – it was very inspiring!’

Is there one patient whose story will always stay with you?

‘On medical mission in Malawi, I volunteered as a paediatric anaesthetist. During screening, I met a little baby girl not yet six weeks old with a unilateral cleft lip and significant cleft palate. This baby’s mother, who was only 19 years old, had travelled 200km to arrive at the medical mission site and was planning on travelling straight back after the screening. She was very worried about her baby and was struggling to breastfeed. As a result the baby was malnourished, very small (approx 2.5kg) and weak. With the help of a local medical volunteer translator, we talked with the mum about the baby’s health and how she might work with our wider team to feed the baby expressed milk and formula in a way the baby could take it more easily. We managed to reassure her and to convince her to meet with the nutrition support team that could provide the help they needed.

While this baby was too young and not fit at the time to undergo surgery, we felt incredibly moved by the journey this mother was going through and extremely hopeful that with Operation Smile’s support this baby would now have a great chance at survival and may be ready to undergo her first surgery on one of the upcoming medical missions.’

Describe the biggest challenges you see for patients where you have worked.

‘Working with Operation Smile in Ghana and Malawi has allowed me to see the need for safe surgery, but also for trained medical staff. Staff for basic healthcare and for work like cleft surgery, are in extremely short supply. Often these countries rely on training specialists through support of international trainers in and out of the home country.

As an anaesthetist, I was fascinated to discover that Malawi has just four doctors in training as anaesthetists, two of whom I met in Blantyre and two out of country training in South Africa.’

Jackie’s Story

Jackie Matthews, works as Clinical Nurse Specialist for South Thames Cleft Service at Guy’s and St Thomas’ Hospital, based at Queen Victoria Hospital at East Grinstead. She specialises in the care of infants and young children born with cleft conditions but she is also an Operation Smile volunteer and UK Medical Subcommittee member.

She has been on missions to Mexico, twice to the Dominican Republic and to Ghana.

Can you tell us more about your medical missions with Operation Smile?

I went on my very first medical mission as a volunteer in 2011 to Guadalajara, Mexico. My role was to help children in recovery just after they had received surgery.

On my second medical mission, and as the only British nurse on the mission, I joined other professionals from the USA, Sweden, Russia and Estonia, flying to Santo Domingo in the Dominican Republic.

There we screened more than 120 babies, children and adults, and had four operating rooms running consecutively, performing facial repairs for cleft lips, palates and other deformities. In total, we performed surgery on 79 patients, the youngest being just six months old – a little boy named Joshua.

I was lucky enough to follow little Joshua through the patient journey, accompanying him at screening, pre-operative assessment and on the morning of his surgery when I recovered him after his procedure and he woke to a familiar face. I was able to answer his mum’s questions and formed a relationship that really helped allay her fears. It was an amazing experience.

What are the main challenges you and the other medical volunteers have to face during a medical mission?

When an Operation Smile team arrives in a new country for a 10 day mission we take much of our own equipment to follow as closely as we can the theatre environment and standards we enjoy at home. Even then on my last mission to Ghana, we had to contend with heat, electrical storms and power failures!

During each mission we have to adapt to the new theatres and hospital environment and its very grounding work, with a team you’ve never met before. We hit the ground running, and have to be confident in our job so that we can meet any emergency and know what to do and who to go to.

Are there any similarities between your job in the UK and the one you do with Operation Smile?

My job is the same wherever I am, of course the conditions vary from country to country, but people are more like each other than we can imagine. When a father at my hospital in the UK hands his child over to me, the worry in his eyes is just the same as in the eyes of a mother in the Dominican Republic when she hands over her teenage daughter. There are many tearful moments when you see a child’s beautiful smile and their parents’ reactions when they see their child after their operation. It is so rewarding to know we’ve played a part in this transformation.

It really breaks my heart every time I meet a child who does everything to hide his or her smile.

Why are you so passionate about Operation Smile?

I consider myself lucky because I can see for myself the difference we can make together – to so many children and their families. My work doesn’t end with a mission – it continues and multiplies as I can tell other people what I have seen. I also love talking about my experiences and showing my photographs to local groups and schools.

None of our missions can happen without the ongoing help of our generous supporters. To help to support Jackie and the other hardworking UK volunteers in their life-transforming work, please click here.

Introducing Dr Annemieke

Annemieke is a paediatric intensivist and a member of the Operation Smile UK medical subcommittee. Annemieke has volunteered for many medical missions, travelling to India, Cambodia, Kenya, Ethiopia, Namibia, South Africa, Jordan, China, Honduras, Paraguay, Malawi, Vietnam and Madagascar.

Annemieke with a patient

What inspired you to first get involved with Operation Smile?

As soon as I qualified as a Paediatric Intensivist I started working with Operation Smile. Living in a Western country I think it’s easy to forget how privileged we are to have excellent healthcare that is safe, reliable and accessible to all.

What I like most about Operation Smile is that we involve local healthcare professionals and medical students, teaching and training them to be able to continue providing medical care after we have left the country.

You were recently part of a medical mission to India with Operation Smile. What did you do there?

I always go as Paediatric Intensivist, team doctor and one of the team leaders. Pre-operatively I’m part of the team screening patients that are eligible for surgery. We come across an array of diseases and disorders and also offer support and treatment for patients that aren’t surgical candidates.

After helping create the surgical schedule I spend most of my time in the recovery room, assessing post operative patients. Because the paediatric wards have no ability to monitor vital parameters and can be quite hectic, I need to guarantee patients have no risk of complications before they leave the recovery room. I always work closely with an excellent team of nurses, who allow me to be flexible in supporting the anaesthetic team, patient wards and continue screening newly arrived patients.

What is it like to be there at the medical mission site as families start to arrive?

Local Operation Smile staff will inform patients and their families several months before the mission starts, providing logistic details such as the location and the available transportation. When the international volunteers arrive most of the families and patients are already at the location being cared for (shelter and food).

We meet patients and families for the first time during the screening process, when we examine patients and review if they are eligible for surgery. On a screening day we usually see well over 100 patients. These days are long, the language barriers can be challenging and we rely heavily on our local volunteers, often medical students, who help us communicate with families and take away any cultural barriers.

I am always humbled by the enthusiasm and patience of the local teams and families. Despite sometimes having waited for several hours to be examined, people are always welcoming and kind. It’s the moments when you connect with a family or share a laugh that makes these days so special to me.

How has volunteering with Operation Smile impacted you professionally and personally?

Having worked in hospitals with extremely limited resources (no basic medications, electricity, fresh water) has reinforced how fortunate I am to have a safe home, access to medical care, clean water and food. I have never needed to question these things as a child, adult or as a medical professional working in the UK.

Working with medical professionals from different cultural, economical and religious backgrounds has made me a better and more compassionate doctor. I love working with an enthusiastic team of professionals that continuously supports and teaches each other.

Meeting patients and families has opened my eyes to the injustices in the world and has strengthened my determination to give back and make a difference in somebody’s life and I hope to continue my work with Operation Smile in the years to come.

Daniel’s Drive: Training Ethiopian Surgeons

Dr. Daniel Getachew, left, and Dr. Per Hall, right, evaluate a patient’s X-ray with Dr. Yonas Exchetu at Jimma University Specialized Hospital in March 2015. Photo: Jasmin Shah.

How did one surgeon’s sleepless night become another’s dream come true?

When the vision of the former, Dr. Per Hall of the United Kingdom, fuelled the relentless drive of the latter, Dr. Daniel Getachew of Ethiopia.

At Operation Smile’s 2018 NEXT Medical Conference, the reconstructive plastic surgeons shared their perspectives on the successes and challenges of the surgical training rotations hosted by Operation Smile at Ethiopia’s Jimma University Specialized Hospital (JUSH).

The commitment of Daniel and his staff cemented the establishment of a 28-bed reconstructive plastic surgery ward in JUSH’s newly constructed hospital. The unit officially opened on Jan. 1, 2018, just days after Daniel returned to Jimma after completing a three-year training program in Taiwan.

His graduation made him the first general surgeon to earn accreditation as a reconstructive plastic surgeon through an Operation Smile surgical training rotation.

“It’s just like a dream come true,” Daniel said. “I couldn’t wait for that day to come.”

While Daniel’s accreditation and his new ward are significant milestones for both JUSH and Operation Smile, there is still much work to be done for the unit to become self-sustaining.

Daniel and Per emphasized this in their presentation at NEXT, making impassioned appeals to the Operation Smile medical community gathered in Norfolk, Virginia, on May 10, 2018.

Daniel, left, and Per present an update on the Jimma, Ethiopia, surgical training rotations at the 2018 Operation Smile NEXT Medical Conference in Norfolk, Virgina, on May 10, 2018. Photo: Marc Ascher.

“This is actually just the beginning of a better future that I’m hoping to see,” Daniel said in front of a crowd of more than 250 of his fellow volunteers from around the world. “So anyone who is interested in coming to teach us and help the patients is very much welcome to come.”

Daniel didn’t know it at that time, but his unit would get another major boost of visibility later in the conference. The day after their presentation, Per was selected as the Operation Smile’s volunteer of the year in honour of his leadership of the Jimma rotations.

Today, as Daniel emerges as the leading plastic surgeon at JUSH, Operation Smile is working with key partners to develop the next layers of training to support the growth of the new plastics unit.

“Carefully crafting programs to locally grow general surgeons and anaesthetists in cleft and plastic surgery skills is key to the success and long-term sustainability of the unit,” said Libby Durnwald, Operation Smile’s associate program officer of education. “It will take the effort, creativity and passion of dedicated volunteers alongside local providers to design a program that lasts for years to come. The next cohort of plastic surgery trainees will be fortunate to have Daniel as a role model, teacher and leader as they work to develop their skill sets.”

Spearheaded by Dr. David Orr of Ireland and Per, the rotations have been conducted twice per year since 2012.

The two-week training courses for Ethiopian surgeons, anaesthetists and nurses have revolutionised how patients receive surgical care at JUSH, the only hospital serving the 15 million-plus people living in Ethiopia’s southwestern region.

The focus of the rotations isn’t only on cleft surgery, but also teaching general surgeons a wide range of techniques to better heal burn, trauma and surgical wounds, which represent the bulk of the hospital’s need for plastic surgery.

“When you go somewhere like Jimma, where they have such a huge workload, cleft lip and palate are actually a really small (portion of the overall need),” Per said. “Every day, you have people with intestinal obstructions, machete injuries, people falling from trees, road traffic accidents, burns – they come in and they have to be dealt with immediately.”

When scheduled cases are delayed by emergencies, the backlog builds. This reveals the immense need for increased staff and training to handle both immediate and elective surgical care in Jimma.

Daniel performs surgery under the guidance of Dr. David Orr during the November 2014 Operation Smile surgical training rotation in Jimma, Ethiopia. Photo: Jörgen Hildebrandt.

The goal is to close this critical gap between the amount of reconstructive plastic surgeons and the people they serve, especially in the country’s more remote areas like those surrounding Jimma. In Ethiopia, there are little more than a dozen reconstructive plastic surgeons serving 105 million people, and most of them are cantered in and around Addis Ababa, the capital city.

Operation Smile Chief Medical Officer Dr. Ruben Ayala said: “I believe that the genius of individuals like David Orr and Per Hall – who believed in the power of training the local professionals way before Operation Smile looked beyond (medical missions) – is that they saw a need that was tangible; it was really in their faces and they couldn’t turn away from it.

“They also saw the opportunity in what Operation Smile could and should offer. They paved the way for us, as an organisation, to start thinking about the impact that we could have on the lives of children and on the lives of entire communities.”

So, back to Per’s sleepless night.

After years of serving on medical missions in Ethiopia, David and Per stepped into uncharted territory when they brought Operation Smile’s first surgical training rotation to JUSH in 2012. Per said that while he knew that the hospital’s general surgeons were skilled, he didn’t know what to expect from their initial attempts at performing cleft lip surgery.

At that time, Daniel was the hospital’s general surgery consultant, and two of his residents were the rotation’s surgical trainees, including Dr. Yonas Yilma Metaferia, who assisted Per on the first surgery of the day.

Per evaluates a patient in need of reconstructive plastic surgery with surgical training rotation student Dr. Yonas Yilma Metaferia in March 2016. Photo: Jörgen Hildebrandt.

“When the second patient was on the table, I asked Yonas if he would like to put the marks on the lip. He did, and I looked, and I thought, ‘Well that’s perfect,’” Per recalled. “I gave him the scalpel and asked him if he’d like to carry on. He then did 85 percent of the second cleft lip he had ever seen in his life.

“And that night I could not sleep. Because I just thought, ‘Wow, we’re starting at such a high level,’ and there was almost an arrogance that we didn’t realise that. These guys had enormous hours of surgery under their belts. By the time they are consultants or attendings, their flying hours are in the hundreds of thousands compared to U.K. and U.S. trainees, and they’re using very limited resources very ingeniously.”

After the first rotation, Per gathered the surgical results of his mentees to be analysed by Operation Smile’s medical oversight team. They affirmed what Per already knew: The results were fantastic and the need to invest in the training of these general surgeons was solidified.

“We can take general surgeons like Daniel and use (the rotations) as a test case to show that you can teach cleft lip surgery to very able people and get results that are comparable or better than some of the outcomes I have seen on other Operation Smile missions. That’s why I couldn’t sleep,” said Per, who acknowledged the further complexities of and training required to perform cleft palate surgery.

Per added: “It wouldn’t have worked without Daniel’s drive.”

“He is so motivated to make this happen, so we are very, very lucky in this project and we need to support him. We need Daniel to train his own surgeons internally and we need to support the supply chain, the consumables and equipment. There is such a lot of stuff that they need.”

Despite the challenges ahead, Daniel is optimistic that the future of his unit is bright.

“I have already established the plastic surgery unit, and a lot of people are getting help from it, so you can see how it’s going to exponentially change the service that we can deliver,” Daniel said. “We can sustain that for a much longer time and we can provide service for the rest of our region.”

Daniel, left, and Per present an update on the Jimma, Ethiopia, surgical training rotations at the 2018 Operation Smile NEXT Medical Conference in Norfolk, Virgina, on May 10, 2018. Photo: Marc Ascher.