A GREAT AND GLORIOUS DAY IN BETHEL BAPTIST HOSPITAL:
BEGINNING WITH A RUN AROUND KAAMULON PARK!
THEN FOLLOWED BY A FULL OR DAY WITH GOITERS,
HYSTERECTOMIES, AND A GIANT SPLENECTOMY FOR HYPERSPLENISM
ALL ACCOMPLISHED WITHOUT A HITCH,
IN TIME FOR THE CELEBRATION FESTIVAL OF THE HOST
HOSPITAL STAFF
Feb. 13, 2002
Finally! I have run! Now, if that is not the answer to prayers for some major event each of us have been waiting for, it is the second most ardently wished for outcome of an early morning opening. The most urgently wished for passing of a major milestone has been rather publicly interceded for and that is a matter that has brought Holly Dolly past prunes to prayer requests for her first grand event of the two weeks’ trip—but we will try to spare you the details which have often occupied dinner table conversations and some devotional prayer times!
This morning, I kept awakening early and thinking of running, and was worried that my thinking of it would turn out to be a substitute for the act itself, so I kicked myself out of my cot at 5:30 AM and got on the outfit and ran down the main street before much of any traffic had started. Other than some dogs and children who were curious enough to follow me along, I was blissfully free of the heavy trucks belching diesel exhaust in my direction. This was not the same situation after the return when the city became alive and very smoky and clouded with dust and diesel fumes. I ran along the back streets to the major park here of Bukidnon, the name of the province, and hence a “state park.” It is strung with pennants that festoon every thing as a reminder of the major holiday coming up next week, called Kaamulon, the gathering of the (eight) tribes of Bukidnon in a celebration of their diversity, previously celebrated by warring parties clashing into each other. The pennants are strung everywhere as a courtesy (reads that as free advertising for) San Miguel beer, a principal local brew. Now there may not be much of the product of this brewery consumed or even present on this Baptist Compound, but that does not mean they do not appreciate the banners in their colorful abundance, so, incongruously, even the church here has that San Miguel banners hanging all around it for the Kaamulon Festival coming up. The manager at MKAVI (Mount Kilgalad Agri-Ventures Inc) has been requested to put up a booth to showcase the new ways to use the bananas that the MKAVI enterprise produces. And other local artisans and merchants are also participating.
A loop of the road around this park extends into the tropical rainforest nearby, which we had driven around in the orientation on Saturday in the rain, but the road was being graded right in front of us on Saturday so would have been rather muddy on any of the other days when I would have had to find my way in the pre-dawn dark. I took off today in an early run that found that trail and a good loop through the forest primeval, running in the rainforest at dawn for the first time since I did this regularly at the Assa compound in 1998. So, after working the aching out of my legs and tight pyriformis, which has afflicted me since NOT running, I got back into the rhythm and will have o do so on an accelerated schedule since I have a marathon to run with Joe a month from now—the Inaugural DC Marathon, a month before the 106th Boston.
I returned to go to the OR, and to begin the day with a thyroidectomy, which went smoothly and swiftly, without a hitch, as I guided Dr. Regan Espina through it. He had been somewhat shaken by the attempts to do the hysterectomy yesterday in which he had a number of hesitations which probably cost the patient several units of blood, so he was somewhat reticent today, hoping he might be able to assist me in a couple of the major cases that were coming up. The next one was a hysterectomy for a huge fibroid uterus, in a woman with a tumor the size of a full-term pregnancy. The operation looked like a C-section, and I was careful to make sure he had each step in control as we went through it. So, in contrast to yesterday, the operation took half as long with 1/4th the blood loss on a uterus fifty times the size, so he was pleased and went on singing the praises of his teaching assistant the Professor.
We adjourned for a big lunch at dinnertime prepared by our household staff of Betty and Willie, with at least five courses, always appending some new tropical fruit surprise. This time the surprise included a purple ice cream called “Ube”—a root crop that is put in ice cream. Topped with bananas, papaya, and mangos, this made for a colorful dessert. By this time I needed coffee to be less drowsy, since a big case was coming up that I had promised I would help Regan do—his first ever splenectomy. This was no ordinary operation, since it is done for hypersplenism, and not of a subtle nature. The spleen was huge and the patient had both anemia and platelet count that was low. This probably followed malaria as an early stage since he did not have Schistosoma japonicum, the next most common cause of hypersplenism, which usually gives bleeding varices from portal hypertension, the reason that the operation was done three years ago when the team was last here on the father of the OR scrub nurse Wilma. She had to drop out half way through the operation to go to give blood for her father, and it was a very sticky and high risk maneuver for that team to be undertaking.
I went over with Regan what it was that the objectives of this operation were, to ignore the big spleen, but to get into the lesser sac of the peritoneum, and expose the very large splenic artery and the even larger splenic vein, ligating the former and leaving the latter open to drain over a liter of blood back into the patient from what it was that was sequestered in the giant spleen. He had had two units of blood last night, and came down with one hanging for wh9ich he was suspiciously hot. He also had dark urine, so I suspected he might have had a transfusion reaction. We treated him with IM paracetimol and also alkalinized his urine so he would not get casts in his kidneys, and then made the epigastric incision.
All according to plan, we entered the lesser sac, and came down upon the very large splenic artery as it entered the hilum of the huge spleen right next to a splenic vein the size of two thumbs. We triply ligated the splenic artery separate from the splenic vein so it would not have a chance of making a later AV fistula, and then careful separated the splenic vein from the tail of the pancreas so as not to get a fistula from the pancreas. I then went around the back side of the spleen and tore all the suspensory ligaments to the posterior gutter without tugging on the short gastric vessels which would be a source of bleeding and through an enlarged abdominal incision, I delivered the spleen onto the abdomen with a lot of ooh’s and ahh’s at its size and menacing appearance.
We drained a full liter into the patient’s circulation without clamping the splenic vein so that we had the patient infused with more blood than he had circulating before the operation, even without the two units he had ready for him, which we returned to the bank for use with someone else. I shrunk down the spleen, but even so, it was still bigger than the liver, weighing over 3 kg. All this was carried out with the loss of 30 cc’s of blood, so that the operation went even better than plan, and as a “worst case scenario” it was Dr. Regan Espina’s first splenectomy!
He was so happy about this post-graduate course in surgery, that he was virtually flying when we got to the next case which was a Moslem woman with a goiter and a humming pulse in the gland which had too much blood running through it as she had a pulse of 120. She had come last year for this operation and was postponed because she was pregnant. So, this was not the time to turn her back. We gave her Beta Blockers IV and slowed her pulse, and carefully delivered her goiter, with minimal blood loss, and early control of the vessels so that this last thyroidectomy was accomplished swiftly and smoothly, which was a big change from the earlier cases since when his confidence has increased with the help of an assistant that feels comfortable in taking on somewhat unusual advanced cases. I believe that the venues of this trip have improved three places in the indigenous care available—1) The Tboli people of TECH at South Cotabato, 2) Bethel Baptist Hostile Malaybalay, 3) and the Baptist Clinic at Leyte, to which Dr. Regan Espina returns after this special tutorial here with the “Professor” as Allen Mellicor had advertised me to get him here. This has resulted in an invitation to go next year to the Clinic in Leyte, two islands north of Mindanao, after we might first get started in Tboli TECH.
Regan told me about the book written by a Dr. Lincoln Nelson, called “Sword and Scalpel” about his experiences here in the area of Malaybalay and early experiences in other parts of the Philippines as well as South America. This same Dr. Nelson also worked in Togo Africa, and now is residing in Santa Barbara California where he has an email address through which I might reach him to compare notes. He has apparently removed thousands of goiters here under local anesthesia, since that is the entire anesthesia he had. The “A Team at Bethel” has made high volume treatment of large goiters possible safely. The patients treated are being done free, and it turns out that the others who might wish to have treatment who could come when the team is NOT here are wiling to pay the charges of up to one thousand dollars, if they have it, but the surgical expertise is not usually available, and in an ironic twist, is available here only to the poor.
We are now prepped for a big event they have been preparing all week. This is the “Lechon” feast and special program of performances tonight for celebration of the MMI team being here and serving the community for the last week. We are going to have to put some kind of performance together as a team to reciprocate their rehearsing and preparing al the week. I saw flowers and Valentine’ s heart being prepared in the decorations at the courtyard behind the hospital where we will be tonight in full voice, with al the patients and the staff joining in to have a mutual love fest the day before Valentine’s Day.
It turns out that we will also celebrate Valentine’s Day itself since we are planning to go across the street to the Pines Hotel next to the infamous Internet Café with the non-functioning emails, and we will have dinner there as a Valentine’s Day celebration in honor of loved ones far away. I am told by Dr. Ruthie, the hospital administrator, that she will make available here own computer with an internet connection so that I might be able to send this and other messages on Valentine’s Day itself back home on a somewhat more reliable message sender than the annoying multiple failures that have plagued my appearances at the Internet Café, and will come to you before the “Serial Letters” I have sent from Mindanao in a series o f four from different venues.
So, I am on my way now to the celebratory festival in our honor, and will hope to send this to you to let you know I have another full operating day—perhaps even another running day—and a lot of further travel to get back to your side of the world before passing through it quickly to the far side in the other direction!
Happy Valentine’s Day!