FEB-B-4
FEB. 9, 2002
I am going to try again. Not only has it been a heroic effort, it is at least as exasperating as anything I have done, certainly on this trip, to try to summarize and then send to you a message about my conclusion of the first half of this experience (Feb-A-series) and the arrival in Malaybalay to begin the second week and the phase to be designated Feb-B-series. I have worked hard on letting you know what it is that I have been doing and the environment in which it has been done, but the net yield from this has been NO communication in your direction, No salvage of any of my efforts against heavy problems in techno-glitches, exhaustion, weather, and time off to do so, and even ERASURE of what I had previously recorded in my after hours efforts stolen from the couple of hours each night that might have better been spent sleeping. But, here I will try again, and at least try to preserve the attempt on a disc, even if, once again, it is not transmitted to you to tell you what has been going on as I move from the first to the second phase in the mid-point of this surgical mission to Mindanao.
AND, FOR REASONS TO BE SEEN, NOT RUNNING
I have just concluded the intensive week of surgical procedures at Tboli Evangelical Clinic and Hospital (TECH)—the one and only week of the year in which any surgical services can be had at TECH, since we are operating in a converted office with equipment that we bring in to use here from donations I had carried in the big box and the more permanent equipment borrowed from Bethel Mission Hospital in Malaybalay, from which I am now writing to you. The team assembled here, small, VERY diverse, and yet surprisingly compatible, is the only chance these people will have such service from not only an expert surgical group, but free services, with the inclusion of support from the same volunteer team for the patients, and accompanying family members, for the transportation from their remote mountain villages to come down to the area of Edwards, where the TECH is located. Weunig (his Tboli name) is our host. He is also known as Dr. Salvi Dagang (as the other Philippino refer to him, most of whom, like Bing his wife, are Visayan, or from some other non-indigenous Philippine environment outside Mindanao, and use a language other than the Tboli tribal language that is what brought Vivien Forsberg here 50 years ago to translate from Wycliffe translators, now known as SIL, Summer Institute in Linguistics.
Last year, I had worked with Salvi himself, teaching him how to do thyroidectomies, even though he is principally a primary care physician, with a bent for political organizing activities and community development among his people. He is the only Tboli physician, and, until recently, probably the only Tboli college graduate. He was one of the people Vivien helped originally when she was working here with Lillian, a spinster pair of women who had started right after the WW II Japanese occupation was displaced by American GI’s and the work began on producing a New Testament in the uncodified Tboli tongue. That has gone through the work to complete three phases, now that the Old Testament has also been translated, and adult literacy programs have been begun, with the third step being the Tboli dictionary, on which Lillian is still working at Nasuli, while Vivien is completing her last two years here in Tboli land working in literacy classes in the language she translated. Vivien got married for the first time, at age 74, three years ago, to widower Don Van Weynen, a South American Wycliffe support staffer and a widower. His wife Mabel and he were married 47 years ago as Vivien was the bridesmaid back in Minnesota from which she came out of a rural Lutheran church. Don’s wife died of a brain tumor several years ago, and he proposed to Vivien. Now, this pair of newlyweds is honeymooning in the last two years of Vivien’s stay here before they return to Michigan, where Dutchman Don’s grandkids are. We stayed with Don and Vivien in their elevated rattan mat house, under heavy guard.
Salvi had political ambitions, and ran for, and was elected Vice Mayor of the whole of the South Cotabato area. This is a high office, and comes along with several of the kinds of political powers he has used so effectively in organizing the TLDFI—Tribal Leaders Development Foundation, Inc. of which TECH is one part, the literacy program another, along with rural agronomy support, water development programs, traditional culture preservation, and cottage industry development, and remote evangelism are all in a package of development pieces for which Salvi has written grant requests to US AID, Australian aid and other sources. He is very politically astute and a very big change from the local politician who in the Philippines, as well as in Africa—or, probably anywhere—are principally experts in graft skimming. Because of his clean and forward looking programs to help his Tboli people, he has been investigated repeatedly, and found to be legitimate, given awards (he left while we were here carrying his original T’nalak woven abaca fiber Tboli suit to go to Manila and the Malacanang Palace to receive an award from President Gloria Arroyo for the “cleanest inland lake in the Philippines”, Lake Holon, above us here at TECH, 10 km from the village known as Salacafe—“the nesting place of hawks.”)
Salvi called the army to say that he had a team of visitors coming a few months later, and that they included a US surgeon and nurses as well as a group from the Philippines who would be coming to do the planned surgical project at TECH. This is a high profile, scheduled event, and I was known from last year’s participation, with everyone in the community tuned in, so that the group would be fixed in a known position and all of southern Mindanao would know about it, including those who might seek an ideal set of American hostages (several are being held at present, and we can point out that it was not all that far away that they were taken under not dissimilar circumstances.) Salvi and the military considered that the surgical team constituted a nearly ideal set of hostage-potentials, since not only could the US government be pressured to respond to demand for their release, but also a surgeon would have money resources of his own that could be demanded for a ransom. So, with a request from Salvi, last year a platoon of paratroopers had been assigned to guard us when we moved from TECH to General Santos, with a stop at a beach. It was a rather bizarre sight to have me and my medical student sitting in a jeepney next to the nursing staff of TECH sitting on sacks of rice and around trussed chickens, with heavily armed paratroopers carrying full automatic weapons and scores of live round-loaded clips in their camo-colored uniforms, as we went to sit on a beach for half a day. Now, for what happened this year in our “Security Contingent”---and I am not sure this makes you reassured for the safety of this mission or heightens alarm!
My “security escort” this year was imposing. A platoon of Philippine Army in full combat gear was around me at all times, along with the National Police and the Military Police. When we left the airport at General Santos, I remarked about the heavy security presence at that airport staked out on all sides of the plane, but then noted that it moved along with me! I said to Salvi, “I see about two dozen military guards surrounding us in a mobile “LZ” that goes with us as we move, along with special police and other uniformed guards.”
He smiled, and replied, “Yes, but you do not recognize the plainclothes guards that area also on all sides of you watching you and the perimeter around you that nothing unusual will be allowed to enter.” He added that at every 10 km along the roads we travel, there are radio linked stake outs and a mobile group of motorbike mounted soldiers with M-16’s along side our vehicles, with the security support vehicles fore and aft as we move. When we get to Vivien and Don’s, there is a scatter as the troops first “re-con” the area, then they camped in the first floor as well as hanging hammocks across the street, behind the house, and on each side, with a rotating guard all day and night.
I watched them as we had come to a stop for gas or for to pick up supplies enroute to the TECH. The first security van with the open sides with al the soldiers leaning out with their weapons would spread out in a fan around us and then pick up a sentry position around us at four quadrants of a perimeter they would be facing inward, watching everyone and everything that moved into the rectangle close to us. If anything looked suspicious, they would crowd closer. They looked quite professional in their positions and their uniforms and especially packing all their heavy armaments. I felt sorry for them as I got to know most of them individually as scared kids. They had to stand and wait—not my favorite use of life and youth, with the only excitement being highly dangerous to them. Most of the time they are assigned such duty it is not for purposes as useful as this one, and they really sympathized with the efforts we were making, since they could see the before and after efforts we made, coming out of the OR.
They were packing US M-16’s with twenty full clips, handing around their necks on Mae West’s of 12.5 kg. Richard had a necklace of live grenades, and the one fellow had an RPG (rocket propelled grenade launcher) a rather heavy mass casualty device for a guard detail. The MP’s packed old M-1’s with wooden stocks and extra clips. These are the “Tanker” M-1 Garand rifles, a WW II weapon. They are surprised that I recognize their weapons, which they have to carry at the ready at all times, day and night. If they should be separated from their weapons, and they are still alive and uninjured, they would be court martialed and would have to reimburse the Philippine government for its loss as well as being liable for anything that was done with it in the interval. I know they are very uncomfortable lugging all this and then standing in a perimeter around me in full battledress and boots, with an extra 30+ kg of firepower upon them as they are guarding a guy wearing scrubs suit and sandals in a mask and funny-looking hat. They seem to appreciate me as opposed to the usual anonymous “mark” they are assigned to guard who might more regularly ignore them. I at least know their names. They want to pose for pictures with me, and they are eager that I remember them, and give them a souvenir of their stay with me---such as, for example, the magic GPS would do just fine, thank you!
When we would move after breakfast, the first thing we would have to do, is to get our guard ready to ride with us in the vehicle the one half kilometer to the hospital. Once, when the vehicle did not arrive, we began to walk, but that would mean that the soldiers would have to deploy ahead and behind us and then have several walking on every side of us, carrying their heavy automatic weapons. It was a large burden to impose on them but they are under orders to accommodate us.
Salvi had told them they would have to make special arrangements for me, sine I would need to run long distances at least every other day. This would mean that they would have to get a group ahead of me, posted along the road. Then they would need two vehicles fore and aft, and then would need someone to run along side me. Richard, the captain of the guard was chosen. But he had only gone as far as one km in his life, and that was not while carrying his large necklace of live grenades with an M=16 and a Mae West of twenty clips of full metal jacket rounds. So, despite the real need I have to put on serious miles, in anticipation of the marathon I have to do as soon as I get back, there is no way I can put that much of a burden on the guard, even though they are under orders to accommodate me in every way they can.
So, for two reasons, the guard being the first, I have not run a single step—and I feel it badly. The second reason is that I have been operating non-stop from well before dawn to well after dusk. So, I have done a lot f cases and solved a lot of other people’s problems in the course of so doing, but I have surely accumulated a few new problems of my own—and that will be apparent about mid-marathon when this neglect will start showing up.
The narrative of the daily events will tell a more complete story about what I had tried to do each day with this rather atypical small and surprisingly compatible team even though diverse. They have all had experience on previous assignments in various countries, although what on earth they could have done there is a mystery, at least for two of them who seem clueless here and seem to mainly stay out of our way when working, showing up for the meals and the cultural events. The core of our team is the threesome of Valerie—acting as scrub nurse, Holly, who is a “Southren Belle Blonde” who circulates, and me as the surgeon. I am usually assisting Janet Molina, the one third of the Philippine “A Team.” She is the Philippine junior surgeon with Don the anesthesiologist and Al the nurse anesthetist who makes everything else work.
Allen Mellincor was detained with Alison Froese who got busted for dangerous drugs transport, after innocently declaring her medication stock and showing all the embossed sealed permission letters from the Philippine consulate in Canada—apparently not enough for some bureaucrats in Manila where they were detained for four extra days visiting offices of the Justice Department and BFAD (Bureau of Food and Drugs) until they were released with apologies and the further layers of paperwork necessary to carry such a drug as atropine! (You figure!) So, our team came in and took over doing one after another of the huge goiters always pushing to do a bit more than either equipment or staff could handle—and somehow they got done. WE would go home exhausted, arriving after dark at Don and Vivien’s where Don would be getting up from a nap since he wanted to take this rare opportunity to play with us, spinning tops and telling us all to stop whatever we were doing while he played a cd of some special song he wanted us to hear. It was fun talking with Vivien and hearing her stories about the early f=days of her work among the Tboli, and her strong reactions to the invading Visayan culture which has taken over the land and assets and in almost every contact, beaten or absorbed the Tboli people who have not been savvy traders with the outside world and had few assets that were trade goods.
When Alison and Allen arrived on Thursday morning, we had already done 30 goiters, and all of them were doing well, with a few cases we had stacked up for further operating—a couple of hysterectomies, a few web contractures from burn scars, a few cleft lips, and a group of hernias and hydroceles. One special case was a huge tumor in the neck that was called a parotid gland tumor, but I had said it could be an atypical mass, possibly ectopic thyroid goiter or an unusual cervical tumor like a glomus jugulare tumor. More about him will be reported in the other narratives of the trip. I will pull out one “climax case” for the conclusion of our stay in Tboli land which happened after al the schedule had been finished and the night after our farewell program with the formal Lechon feast for all participants. This woman’s story probably illustrates the triumph and tragedy of the poor people who have no access to care, and are desperate for help.
A single case may be easier for you to relate to than the report of the number crunchers who are commissioned to follow us and write down numbers: 59 major operations (39 of them thyroidectomies for huge goiters), 7 minor operations, 591 consultations—before I stopped counting on the fourth day. Now, let me give you a real and much more human approach to what this intensive week brought to us, and to them, climaxing with the last case of the week, as we were already pre-programmed to be on our way.
The “A Team” packed up on Thursday night to go back by pickup to Bethel Hospital in Malaybalay, and we had a schedule of about seven cases for Friday to finish off before we packed up to be ready to go up to Malaybalay by air on Saturday. Amid the follow-ups as I pulled drains and changed dressings, the fellow Samuel, who had had the big cervical tumor resection of the glomus jugulare and had been transfused from a donor unit drawn from the arm of one of the volunteer nursing personnel from TECH crashed and had a stroke. While I tried to finish up the ward rounds and get the cases started, Allen resuscitated the patient and moved him to a private room, where he was breathed by an AMBU bag ventilation by the nurses—a process, that to the best of my information is still going on. I then heard that there was a woman who had been carried from up the mountains over Lake Cebu who had an enormous abdomen, and could not lie down flat since she had compression of her cava and interference with venous return by a big abdominal mass she had carried for two years but suddenly had caused her serious trouble. I saw her and found a very distended abdomen with a tense fluid filled peritoneum but without peritoneal signs of irritation. I cut off an IV catheter and cut several holes in it, and under local made an incision in her lower midline, and threaded the catheter in to drain out an old chocolate colored thick fluid that looked like old engine oil. She obviously had an old hemorrhage into her belly, and a likely source of this might be an infracted large ovarian tumor. This was the kind of tumor confronted by Ephraim McDowell on a kitchen table in Kentucky before the advent of anesthesia that brought about the days of successful abdominal surgery when he excised this huge ovarian tumor and saved the woman’s life—fortunately for him, since there was a crowd of onlookers outside the kitchen waiting to lynch him if he cut into the patient and thereby killed her.
I drained the abdomen slowly—and not just a little---over 21 liters by the time we were finished with the last goiter and a couple more hernias. The staff was all exhausted and it was time to pack up. No one was eager to take on another case, and Dr. Bing suggested that she was not a good operative candidate, since she had only 9 grams of hemoglobin and no donor candidates with her. But we had to do something of r her since she was going to die a very miserable death and there were no other surgical teams around at least for another year until we returned again, and she would not last a day, let alone a year, and there would be no one eager to take her on as a free charitable act of mercy anywhere else.
We went to eat dinner, and pretend we were resting before we came back at just before eight o’clock. I lay on the other ersatz operating table until it was time to prep her. I got up, smeared iodine on her belly and made an incision below the catheter I had placed earlier –about 50 pounds of fluid before—half her body weight. On incision, we found a white deflated ovarian cyst about the size of a spare tire. One clamp, a quick tie, and she was finished—a shoestring catch buy the fortunate combination of the grace of God and our presence for one hour longer than we had intended before packing up to leave.
AND LEAVE WE DID,
AS I SAT IN THE CO-PILOT’S SEAT OF A PIPER NAVAJO
IN A FLIGHT FROM SURALLAH TO NASULI
TO TOUR THE SIL HEADQUARTERS AND RETREAT CENTER,
THEN A JEEPNEY TO MALAYBALAY AND THE BETHEL HOSPITAL
In a previous complete description—which you will never read since it was deftly erased irretrievably, I had described the leaving of TECH and our guard and the flight 126 miles north to Nasuli, and the further road trip 134 miles north of TECH to be in Central Mindanao here at Malaybalay. You may yet get the story from the attachments, but I will tell you why you are not getting them now.
SENT TO YOU, FOILED FOUR TIMES OVER BY POWER FAILURES,
INCOMPETENT HELP AND THE VAGARIES OF PERSONNEL AND PLUMBING IN CENTRAL MINDANAO
This story may sound familiar to you since it seems to happen regularly in these environments. I was eager to send you a message on arrival in Malaybalay where there is allegedly both a phone and electric power and even the Kovacs Internet Café! Right! So, I used the entire afternoon of the only free time I will have in Mindanao—not running as I should be, but it is raining heavily, after all, and zipping over to the Internet Café.
I stood in a queue for a long time, since there was a horde of seven-year old Philippine kids zapping invading commandos on very realistic bloody games of savagery at high decibels with car chases and bombs bursting in air. When I finally got to a machine, it did not have a working space bar, so I had to go back and separate each word in the continuous line by hard work. But, this was my one chance to communicate, and I handed them the disc to be attached, which held the stories I had spent precious hours near midnight when I should have been sleeping recording narratives of this experience to send to you. I typed non-stop for two and a half hours. I then had to go back and separate each word, and spell check it manually. OK, now I might try to attach the disc chapters, but before I do that, I will ask the young (about fourteen-year-old) who works here collecting my money for the time on the machine: “Now, how do I save this to be sure it does not vanish? This has happened to me before and I never want it to happen ever again! So, before I send it, make sure it has been saved and then we will attach the disc.”
“Easy!” she said, and with three deft strokes she ERASED the entire message irretrievably. “Sorry! That will be two hundred pesos, please!”
I could not believe it. I thought if I could only stay calm, I could repeat the summary of events in briefer version and try to send it without either saving it or attaching any other chapters myself without such swift and totally efficient help. I worked another hour. I had just begun to separate each word in the stream and was about to send it when the power went out. There is no functioning electricity in the town today, so the Internet Café was the only one open because it has its own generator, but apparently it has only one supply of fuel which was gone without warning—as was the entirety of what I had typed---AGAIN!
When the generator started again and I went through the long process of logging in to start all over, I could not do any more typing after having a very intensive e afternoon when more than anything I had wanted to sleep, and then if there was still light, perhaps to run, even through the rain, I typed in the addresses of the recipients I had wanted without any message, and asked ANOTHER employee (this one all of seventeen) to help me attach the messages from the disc. “No problem.” It is not quite straight forward since they have only a networking relationship with a single computer that can take a disc from the A-drive and I would have to import it and send it out as an attachment from this other machine which would take a while to access, but “Hey, it is no problem!”
So, that is how the second employee ERASED my disc!
I have spent half a day and could not even think of re-trying, having come out of an effort almost as intense as the comparable amount of time spent operating at TECH on the only time off I would have—all of it wasted in such a way so completely as to come out with LESS than I started. So, I have come back to the Bethel Hospital Guest Quarters and simply went to bed—even if it was only eight o’clock. I have tried to get up very early to start—first restoring a few of the chapters from my hard disc onto the erased floppy, and second to give you about half the summary text I had typed up twice yesterday. I will now go walking through Malaybalay in the rain to see if there is electric power in the town, and if there is another Internet Café open anywhere.
This foreign medical mission bit is just a lark, a holiday vacation, and telling you about it is just a “Leetle Bit of a Cake!”