On Wednesday, May 3rd, I came back to Santa Domingo, two years after my last Operation Airway mission to the Dominican Republic. Once again, I was there to help Dr. Marcos Mirambeaux, a wonderful, kind, and competent surgeon, to teach him more about complex airway surgery and about how to build his team to help the children of his country with tracheostomies. On our last mission, we had screened thirteen children and operated on three—I was pleased to see Marcos has decannulated two of the three and one is well on his way! I came back at Marcos’ request to see a new set of patients he had questions about, continue his training, and help him build a new team. Marcos had been worried that the last hospital where we had operated in had an ICU with a high rate of infections and he wanted to move the mission to a different hospital where he said the ICUs were the best and cleanest in the country. This was a great idea!
Today, we arrived at the beautiful Hospital General de la Plaza de la Salud which is a 240-bed hospital, which cares for adults and children. It has a fully functional PICU with nine beds.Perhaps even more importantly, Marcos has is now working with a new team of anesthesiologists and ICU
Perhaps even more importantly, Marcos has is now working with a new team of anesthesiologists and ICU providers focused on providing the best possible care for children with compromised airways in the Dominican Republic. First mission: Accomplished.
We met some wonderful children and their families today and it was remarkable what a close relationship Marcos has with these families.
Our first order of business was to see the children and the families we had operated upon on our first mission in 2015. I’ll just mention one here:
Luisa was a 5-year-old child with a congenital laryngeal stenosis and a trach when we first met her. She was our first case with Marcos here in the Dominican Republic. Together, we performed a one and a half stage airway reconstruction, a procedure we developed to ensure safety while operating abroad on such missions but now which we routinely employ in the States.
Here she is (right image) 2 years later, trach free, with Marcos and her mother.
We saw the other children as well. Only one still has his trach and Marcos is almost there getting ready to decannulate him.
This year’s children (2017)
Daibelis is a 3-year-old who was born with a ‘web’ between her vocal cords, which means, although she breathes and eats quite well, she cannot speak above a whisper. Because we worry that children with such webs have other medical or genetic conditions, our first step was to get an echocardiogram to rule out any heart anomalies that might make surgery riskier for her. Once we had determined that her heart was healthy, we began brainstorming about how to give Daibelis a voice.
Removing the web was straightforward but complicated by the fact that after surgery in this delicate area there would be nothing to prevent the two edges of the cords from adhering to each other or to anything else that we placed there to keep them apart while they healed.
In true global surgery form, I taught Marcos a technique that I, in turn, had learned from an English surgeon some years ago. We harvested a skin graft from Daibelis’s upper thigh, flipped it over so the shiny skin side was down and sutured this to a breathing tube. We placed the breathing tube in her airway, creating a tissue band aid to protect the cut surfaces of the vocal cords so that they could heal properly. Marcos will remove the tube in two days and, if all goes well, I will be sorry to miss Daibelis’ first words in her new, strong voice!
Our second patient was young Edgar. Edgar is a 10-year-old who was trached after a prolonged infection from staph septicemia in September 2016. Once we did his bronchoscopy, we realized why he had been having trouble capping his trach. The trach had pressed into his airway, producing an inflammatory granuloma ball that would have obstructed his airway if his trach tube had just been removed.
Candy was our third patient. She is a 9-year-old girl who became very sick form Dengue fever several years ago and was intubated for a prolonged period of time. Believe it or not, she still has the same trach in place that she had when it was first put in. She never changes it and comes to the hospital when it needs to be suctioned as there is no home suction equipment (here is a place we might be able to help in the future). She is bright and beautiful and can eat and speak with her trach. She can’t cap it though without working to breathe. Marcos tells me the trachea just above her trach, what we call her suprastomal area, is collapsed. Back home (in the States), she would be a perfect candidate for a tracheoplasty with an external stent.
One of the great things about being in this new hospital is that there is more equipment available. Marcos called around and was able to find a plate used to fix a child’s jaw when broken and some tissue glue so I could teach him how to fix such cases and help Candy.
We were all prepared to help Candy. We performed a bronchoscopy and saw her airway. Unfortunately, her airway looked very red, angry, and swollen, and despite all our planning, we felt it safer to keep her safe by giving her antibiotics. Her parents were sad but so understanding. She will be the first child we help when we next come back!
Miguel is a 19-year-old who sadly fell off his motorcycle a year ago, suffered many injuries, and was intubated for a long time while he healed. Eventually, he was trached and now he has absolutely no voice and has what must be a complete scar. Marcos has learned to rebuild airways with rib grafting but wants help refining his skills in airway resection and re-anastomosis.
Miguel had a very difficult problem. After his trauma and his prolonged intubation, he had a dense scar completely obstructing his entire upper trachea. This was the reason he could open his mouth but no sounds would come out at all. We could not fix Miguel on this mission as we might have to put him on bypass while we fixed his airway. He was exactly the reason we have formed a wonderful relationship with the Shriner’s Hospital in Boston as he is someone we will work to bring to Boston.
Arizon is a wonderful, cheerful 19-year-old who smiles even though you can hear him breathing at rest as there is a clear obstruction below his tracheotomy tube. He had a car accident about a year ago. He broke his jaw in several places and broke his legs. They tried to perform a surgical airway (cricothyroidectomy) but had some issues. They were then able to intubate him and eventually trach him.
Now, he is healed but an office scope today shows a granuloma right at the tip of his trach and a tracheal stenosis just above the carina (where the tubes that extend to the left and right lung take off). I was able to show Marcos how to use steroid drops through the trach which will help with his breathing short term, but to fix his airway, he will need to come to Boston for further care as he may need ECMO or bypass while we do this.
Finally, Jaylin is an 8-year-old who we saw on our last mission. He has a blood clotting disorder, Factor VIII defiency, and we were not prepared to operate on him due to his medical condition during the last mission. He had suffered three strokes, had fallen ill and was intubated for about a month before Marcos placed a tracheostomy. He has a mild subglottal stenosis but Marcos felt he could breathe on his own. When he decannulated him, he sutured close the stomal opening (the opening in the neck where the trach had been) and Marcos and I discussed today how different that is than how we do things back home (where we leave the hole open and allow it to close over the next month and then close it if it is still open then). I think Marcos learned something as to how to better care for his patients today. Jaylin was re-trached emergently and I evaluated him today. Marcos does not have a fiberoptic scope to look at if the vocal cords and this would help him so as we diagnosed bilateral vocal fold immobility (probably due to the strokes) which must be why he failed decannulation before.
I think Marcos learned something as to how to better care for his patients today. Jaylin was re-trached emergently and I evaluated him today. Marcos does not have a fiberoptic scope to look at if the vocal cords and this would help him so as we diagnosed bilateral vocal fold immobility (probably due to the strokes) which must be why he failed decannulation before. In our country, we might do a vocal cord cordotomy or lateralization; here a single stage posterior cartilage graft reconstruction would work just as well. I do wish we had a speech pathologist to do a swallow study here and this is another note to address on subsequent missions!
What a short but successful trip. I came down to screen patients for future larger trips, to help Marcos learn some techniques that could ripple on to help other children, and to identify some children whose care was best served back in Boston.
There remains so much to do. To locate basic equipment such as soft endotracheal tubes with cuffs that won’t produce airway scars so easily, trachs so that these children can actually have more than one in case that one breaks or plugs, suction equipment so that these children don’t die at home with their trachs.
That’s not to say how to find a way to bring the kids that really need complex care up to Boston, to get their visa, to find their families temporary homes while their children are there, and to keep them safe and care for them to the best of our abilities. There continues to be so much to do! This collaboration between Operation Airway, Massachusetts Eye and Ear, the Massachusetts General Hospital for Children, and the Shriner’s Hospital is just beginning.
Next year we are planning follow-up trips to EL Salvador as well as the Dominican Republic to continue the work we have begun together.