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Born with a cleft palate, Andres Garcia, 4, is held by his father wile his mother looks through a window while awaiting surgery at El Hospital Escuela Oscar Danilo Rosales Arguello in Leon, Nicaragua, on Oct. 2, 2011. For 20 years, physicians with UW Hospital have been working with doctors in Nicaragua through Eduplast, a non-profit organization which offers medical providers in Madison a chance to collaborate with their counterparts abroad and improve the lives of the country's financially-challenged population. 

JOHN HART — State Journal

LEÓN, Nicaragua — Seven doctors and a surgical tech from Madison plunged into a sea of need: parents clutching toddlers with cleft lips and cleft palates, women hiding faces with grotesque bumps and birthmarks, men whose crooked noses suggested car crashes or bar fights.

A baby smiled through a mouth two times too wide.

A boy’s thumb and index finger, fused since birth, protruded beside a gap for his missing middle finger.

A girl with a stub of an ear stood by a woman with Elephant Man disease.

More than 70 patients gathered, most sitting on wooden benches in the hot, cramped, open-air waiting room of León’s public hospital. Some had traveled from hours away.

They were waiting for the American doctors to join Nicaraguan doctors and perform the transformative magic of reconstructive plastic surgery.

By the end of their visit last month, the UW-Madison doctors would be reshaped, too.

There’s a multifold purpose to Eduplast, a nonprofit organization that has brought medical teams from Madison to Nicaragua for 20 years.

The group helps scores of patients who couldn’t otherwise afford to have their defects repaired. It trains Nicaraguan doctors to provide more of the services themselves. And it picks up tips on how a resource-deprived health care system accomplishes so much with so little.

“We learn how to be a ‘MacGyver’ and do what you have to do in any situation,” said Dr. Delora Mount, a UW Hospital plastic surgeon who has gone on 10 trips to Nicaragua.

With pigeons in the hallways, crickets on the operating tables and six patients or more stuffed into sweltering rooms the size of an American hospital room, León’s El Hospital Escuela Oscar Danilo Rosales Arguello seems as if it’s another planet, not just another country.

But the surgical mission here, in the second poorest nation in the Western hemisphere (after Haiti), is the same as anywhere: reducing stigma by restoring a more normal appearance.

“Every parent wants their kid to be normal,” said Dr. Michael Bentz, UW Hospital’s chairman of plastic surgery, who has been to Nicaragua seven times. “Our goal is to get them as close to normal as possible.”

Reconstruction

When Ricardo Aguilar was born, doctors hovered around him so much his mother thought he was dead. He was healthy but had a rare defect: an exceedingly wide mouth, with bulges of cartilage below each ear. He resembled Batman’s Joker.

Martha Aguilar was first in line when the Madison doctors arrived, and her 5-month-old son was first to receive surgery.

The surgeons snipped off layers of his elongated lips, stitched up the excess gap of his mouth and clipped his cartilage tags. Within three hours, the Joker was gone.

“He always looked beautiful,” said Aguilar, 32, who earns a decent salary as an agricultural project manager but said she couldn’t afford to pay for her son’s surgery, which was provided for free. “Now, he’s even more beautiful.”

Hanzel Membreño was born with cleft hands and cleft feet, V-shaped deformities known as “lobster claws.” Each appendage was missing a middle digit, with the thumbs fused to the index fingers and the big toes to the second toes.

Surgeons generally leave cleft feet alone, and the boy’s right hand was too deformed for surgery.

But his left hand could be improved, the Madison doctors decided. The lively boy was having trouble gripping or eating with either hand, said his mother, Leslie Palma, whose husband works in a car parts factory that is one of León’s main employers.

Bentz and Dr. Carolyn Rogers — a surgical resident, or doctor-in-training, at UW Hospital — separated Hanzel’s index finger from his thumb. They shifted the index finger to where the middle finger should have been, creating a web to the thumb.

“It’s like moving a house to a new foundation,” Bentz said. “Now he should be able to grasp.”

The doctors cut off lumpy tumors from the lower back of the 38-year-old woman with Elephant Man disease, or neurofibromatosis.

For the 9-year-old girl with a stub of an ear, they removed cartilage from two of her ribs and sewed the pliable pieces into the shape of an ear. They carved a pocket of skin above the stub and inserted the makeshift ear. It looked remarkably real, though it will never hear as her other ear does.

Temporary relief

After 33 surgeries over three days in León, a colonial city not far from the Pacific Ocean, the Eduplast team was off to Matagalpa, in the mountains of central Nicaragua. Another throng of patients awaited their skills.

Wilmer Zeledón, 21, lost his lower left leg in a motorcycle accident while working on his father’s farm. The crash ripped most of the skin from his lower left arm.

The doctors used a dermatome — which looks like a large, mechanical cheese slicer — to harvest thin layers of skin from his good leg. They rolled the slices through a mesher, which punched holes in the strips like dough atop a pie.

Dr. Emilio Rugama, a surgical resident from the medical school in León, joined Rogers in stitching the strips across the fiery arm.

Zeledón, wrapped in bandages, recovered the next day in a bed shrouded by a net to keep mosquitoes away. He moaned from pain but said he was grateful for what the surgeons had done.

Another patient, 16, bore a thick, vertical scar across his left cheek from when robbers slit his face at age 3 and killed his parents. Dr. Gustavo Herdocia, from Nicaragua, removed the physical scar, if not the emotional one.

The doctors repaired more cleft lips and cleft palates. The defects are only slightly more common in Central America than in the U.S., but they rarely get operated on as early in children’s lives because few native doctors are trained to fix them.

A photo of one man, age 30, showed he still had a greatly disfiguring cleft lip. He was scheduled for surgery in Matagalpa but didn’t show; the doctors never learned why.

Hilda Martus, 31, wasn’t going to miss the chance to seek an improvement to her blemished face.

Born with a venous malformation, or abnormal blood vessels, a discoloration on the right side of her face contorted during her teens into masses of bumps and blisters on her cheek and forehead.

The contrast with the smooth, serene left side of her face was striking. She had a simple request: Could the doctors stop the incessant bleeding from two of her purplish welts?

Mount, one of the UW Hospital surgeons, delicately cut away the woman’s thin, diseased skin and blood vessels, and covered the areas with stronger skin. Martus would need an extensive tissue graft to more fully treat her condition, but such operations are too involved for the UW-Madison doctors’ short stay.

Martus said she was happy for the temporary relief but hoped to undergo more surgeries someday.

“I want to look normal,” she said.

The doctors did 19 procedures over two days in Matagalpa, then headed back to Managua, the capital city, to fly home.

Training residents

It was Eduplast’s 40th service trip to Nicaragua since the nonprofit started in 1991.

The organization’s founders, Drs. David Dibbell and John Noon, visited the country in the 1970s and 1980s, trying to ease the backlog of need for reconstructive surgery. The need grew with injuries from a civil war in which the Sandanistas assumed power in 1979 and the U.S. assisted the rival contras.

Dibbell and Noon decided they could have the greatest impact if they trained Nicaraguan doctors to do reconstructive procedures themselves.

Their first trainee, or resident, was Herdocia. He now is a plastic surgeon in León, home to one of the country’s two public medical schools.

The Madison doctors select a new resident every three years. Rugama, the resident from León who worked with the Madison team last month, is the sixth overall.

Eduplast pays Rugama’s salary. American doctors visit at least twice a year and conduct in-person training. The doctors and other medical staff primarily come from UW, St. Mary’s and Meriter hospitals but also from other states.

Rugama watches lectures webcast weekly from Madison and will spend a month in Madison next year.

When he’s finished, Rugama said, he plans to work in a region of Nicaragua that doesn’t have a plastic surgeon, as his predecessors are doing today.

“It’s a multiplier effect,” Noon said. “We really catch up on the backlog.”

The program has been so successful that the Nicaraguan surgeons now are equipped to handle many of the country’s reconstructive surgery cases themselves, Bentz said.

“We’re getting close to teaching ourselves out of a job,” he said.

Learning experience

Eduplast has started similar programs in Ecuador and Mongolia, and the doctors say they’ll continue to go wherever there is a need — as long as funding allows. They mostly pay for trips and supplies themselves but do some fundraising.

It’s clear the doctors benefit from the experience, too.

In Nicaragua, Rogers, the UW Hospital resident, assisted Herdocia in a surgery to repair ptosis, a drooping eyelid that impairs vision. She had never done the procedure before. Herdocia has done more than 115.

“He’s the expert, so it was a great learning opportunity,” Rogers said.

When Rogers and Bentz had to put a pin in the finger of Hanzel Membreño, the boy with the cleft hand, no power drill was available like in Madison. They hand-cranked a manual drill.

The anesthesia machines in Nicaragua generally don’t have monitors for temperature or carbon dioxide, and their blood pressure monitors sometimes fail, said Dr. Deb Rusy, one of three anesthesiologists on the Eduplast team last month.

The doctors used stethoscopes to listen to patients’ chests to make sure they were breathing properly. They took temperatures manually and measured blood pressure with cuffs.

When the power went out twice during one surgery, the anesthesia machines had back-up batteries. But the doctors were ready to squeeze an oxygen bag to help the patient breathe and supply anesthesia medications intravenously if needed.

The Madison doctors brought 11 boxes of supplies — syringes, needles, knives, gloves, medications, sutures, scopes, some of which they donated — but still didn’t have everything they have at home.

To prop patients’ noses open after surgery without nasal stents, for example, Rogers fashioned stents out of tubing normally used for urinary catheters, with Herdocia’s help.

Adapting on the spot makes the doctors, especially residents such as Rogers, better equipped to respond to emergencies at home, Dibbell said.

“A surgeon has to be confident that they can overcome obstacles,” he said. “Coming down here and working under more difficult circumstances ... gives our trainees that kind of confidence.”

Most of all, Bentz said, the trips strip away the complexities that can make health care in the U.S. cumbersome: insurance denials, administrative paperwork, lawyers.

In Nicaragua, he said, the Madison doctors do surgeries and see smiling faces as a result.

“It’s pure medicine,” Bentz said. “This is why we went to medical school.”

Contact David Wahlberg at dwahlberg@madison.com or 608-252-6125

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