THE NEXT FULL OPERATING DAY IN EDWARDS
BEGINS WITH THE MEN WITH HYDROCELES,
AND AN UNUSUAL BREAST CANCER IN A MALE,
AND CONTINUES FOR AN EVER-EXPANDING PRE-OP LIST
January 14, 2003
I, along with many of the team, was exhausted and drowsy last night as we made our way to the house for dinner of tropical fruits and fish and rice. The nadir of our day would have us here at the time they think would be a good time for group devotions. This is eleven and a half time zones from the Eastern Daylight Savings Time and a calendar day later by the resetting of my watch, so it would not be the best time to do anything except to stare in a fog of time warp looking for a place to gracefully retire from the ever-present convivial companionship. The male anesthetist of our group took this chance to go to bed and skip dinner saying he might not be up and around in the morning. This would reduce us from three OR tables to two even as we are expanding the number and variety of cases we are booking for OR in side by side cases. This is compounded by the knock on the door by relatives, friends or employees of the compound who are seeking out special connections to intercede for a patient or two who have been waiting all day, who wish to be seen by “the Professor.”
THE LIST OF PATIENTS GROWS LONGER WITH INTERESTING ADD-ONS
This latter case was a very interesting one. A village pastor had had a lump in his left breast in 1994 and it was removed and called breast cancer—a rare but possible condition that is not often survived. He had been treated in 1993 for Tb. He went to the provincial hospital with a large fungating mass over his left chest that they thought had represented a recurrence of his earlier breast cancer, which it certainly does look like, but it would be an unusual disease-free interval for which it could have occurred. There they got a chest x-ray and said that he had a recurrence of his Tb and restarted him on anti-tb therapy. Now he has both this large and growing larger mass on his chest and an unknown status what his lung disease might be, on top of already known asthma and possible Tb. This all needs to be sorted out, and he will be here in the AM for a biopsy of this mass, which, thought very large, is still capable of being resected, not yet fixed to the chest wall. The closest pathologist is in Gen San City, and an arrangement can be made to “text-message” (the Philippines is the world leader for this very good use of the cell phone messaging system of cheap long distance communication for short messages.)
As I returned after lunch yesterday—made memorable by the delightful guayabana juice squeezed from the large green fruit right off the tree in the backyard—I stopped off in clinic to see Bing who was triaging a group of 180 patients who had come today for hoped for treatments that would come free by the group of visiting surgeons. As I stepped in, a scramble occurred and six short Philippine men stood at respectful attention behind a group of obvious goiter patients as a group of mothers held small babies with complaints they had hoped would be fixed.
The goiters were obvious and some of them huge. One man particularly had a large pendulous goiter about the size of my second patient we had just completed this morning as I assisted Dr. Ragon Espina my “tutee” this whole trip as he goes from Philippine physician to seasoned surgeon in the distant clinic of Leyte. There were seven of them in all. And each of these seven goiter patients was being set up to have their preps done and fitted into the limited schedule of our presence here in Edwards at TECH. Then I looked at the six men each of whom stood with worried but silent respectful leg spread stance and waited embarrassed for me to examine them. Each had hydroceles, the embarrassing distension and collection of fluid in the sac around the testis which gets larger and tenser, often interfering with their ability to pee without obstruction. In Africa, the rate of hydroceles is taken as a proxy for the presence of filariasis, which is not present to my knowledge here. So, why, each time I have been here, there is a long queue of such men from remote villages with the same problem is not known to me. This would be a good epidemiological problem worth investigating. There is a special form of filaria Philippenensis but I do not know anything about it, and it does not cause the lymphedema of elephantiasis as does the African variety I have studied.
A SECOND FULL DAY IN THE OR
NEGINS WITH A RAPID SEQUENCE OF HYDROCELES
AND ENDS IN AN AFTERNOON OF MULTIPLE GOITERS
I started the morning with a computer glitch in which I had typed up the text seen above and some further unknown part of it, when the message “Word cannot create the Document” appeared on the screen. I remembered having some idea what this meant since it always preceded a freeze-up and crash of the laptop when it had been seen before, but I kept typing for another page before I saw the freeze occur, and no evidence that anything had been or could be saved. The cursor is immobile, so that I cannot try to use any of the frozen commands to make it possible to save the text. I held off through breakfast, and asked others who had some information about the use of computers, until I had found that I was as expert as any here, and that was not enough. When the machine is adamantly unreliable like this, there is not even the option of turning it off by the usual shutdown mode, so I simply pulled out the battery and unplugged it to stop the incessant threats that all data would be lost since "Word could not (actually, would not) create the document. “Microsoft hath given; Microsoft hath taken away”; under no stretch of anyone's imagination should I further add: "Blessed be the name Microsoft." Already the machine refuses to let me use me enough information to let me back on the computer or into the save mode, so all I could do is pull out everything and hope there would be some evidence of a recovered document. The first pages are apparent above, but there is still no ability to paginate or other simple and necessary steps.
So, after a busy day operating, I have returned having forgotten my rage at futile technology that absorbs all the investment in expense and effort, but returns a zero yield in the final product, so I do not remember how much further I got into the text than the first (unmarked) pages suggest. At least I have maintained a rather complete photographic and audiotape record, right?
I went over to the recovery room to see the post-op patients of the nine goiters I had done yesterday, and saw no one there. After all, they were better, so they were on their way home now! One of the patients did something for me that was heart-warming and effective. She had all her family here, and she was very worried about one big thing before the operation when I had seen her along with two dozen pre-op thryoidectomies. She was very concerned since she was a teacher of voice and a singer in the church, and had heard from someone that the operation might end her singing as it had for some one here some years ago, and she would not want to have the badly needed operation if it ended her singing career. I had explained to her and to her family who accompanied her here that the risk was never zero, but that with the size of her gland she might become hoarse on the continued growth of the goiter alone. I also told her I understood her devotion to her singing career, since I was close to someone who could not give up her singing career either, even if it endangered her life. I said that from the size of her gland, and the fact that I had promised her I would be doing it myself, that we would simply do the best we could, God helping us, and I thought that her risk was lower than the statistical average would indicate, and that I would promise to do my best and she would promise to sing for me the morning after the operation.
She came to me as I walked over to the OR first thing, and there she came to me and began to sing a beautiful aria as a prayer of thanks. I immediately ran around to pick up the tape recorder, and it let out a loud screech, indicating that its batteries were down. I taped it anyway, since a crowd had gathered, to see the unusual sight of a woman with addressing around her neck and a drain dangling from her incision, singing well and gratefully after her operation. This was the third consecutive piece of technology that had failed me in critical moments, but I decided to ignore the times that the less reliable machines failed and concentrate on the more reliable times that the patients did well and biology triumphed in adaptation, despite a lot of circumstances militating against it. I would rather that all the people continue to flourish and that the machines periodically failed than flawless machines and failing people, but unreliability at critical junctures is a mark of futility despite all the best of intents, efforts and expense in trying to set up such moments. But, here we are and the patients and I are both doing well, Thank God!
I launched into the first of the hydroceles patients, and did it so swiftly, that Jennifer who was assisting me, hardly saw it happen under her eyes. The next one was one I had judged to be 400 cc on the left and 350 cc on the right and I did a bilateral waterbottle repair with Ragon, each case with a single length of our increasingly precious suture. In fact, in a matter of minutes, something less than the time needed for the spinal anesthetic in each, each of the hydroceles was repaired and each did well.
I ducked over to clinic to see the pastor with the large breast cancer fungating off the left chest wall, and did the incisional biopsy and a touch prep cytology so that the single pathologist in Gen San City can report back to us by text message, since a family member of his hand carried the specimen for his report, so that I might be able to operate on him before the end of the week if the biopsy report can be delivered to us. We were going to break for lunch, when the patients who had thyroidectomies yesterday were lined up under the trees in a cool patch of shade along with two of our camouflaged regular Philippine Army platoon of guards, armed to the teeth, and lunging on what must be rather easy duty for them, despite the rather high profile terrorist target this project represents. There was the woman who had sung for me earlier, with several of the other women who had had thryoidectomies and even one of the men. Her family and included among them, several small children, had prepared a little songfest of thanks and wanted to perform it for me as they were getting into a van to be leaving, having got the treatment for which they had come with all the misapprehension that came along with them before the p[procedures were done. By this time, I had gone to collect all the new batteries I had carried with me and replaced all of the batteries in the critical equipment I still have, using up all my reserve battery stock. So, I captured the song performances well on this occasion, and hope that the computer glitches might also be self-healing as the patients certainly seem to have been.
AN AFTERNOON OF THYROIDECTOMIES FOR GOITER
I went back to the OR after lunch (which included “taro” –the Hawaiian “poi”) I went back to do several consecutive goiters, each one bigger than the one before it, and despite these “degrees of difficulty”, each was faster and better done than the ones before. I did one with Jennifer quite swiftly for a large solid multinodular gland, and then did a whole string of them with Dr. Ragon Espina, who is visibly and rapidly maturing as I watch with a lot of directed instruction, which is becoming consecutively less, as he is getting more confident, still cautious but also faster in managing these problems. When we go up to Leyte to raise his flag over his own clinic there, we will have several goiters and a thyroglossal duct cyst to operate on, but he difference is that we will have no anesthesiologist there, and will operate under our own administration of anesthetics, local and otherwise.
And, now, after another score of patients operated on by the whole team to day, the recovery room was never empty, and each time the patients seen therein were different, since, like the cruise of oil that never ran dry, as quickly as we send patients there into the new beds shipped over here in an MMI container since our last visit, those beds are emptied by the curatively corrected patients getting up and walking home, all within the day of their operation, which to this moment, once again, Thank God, seem to be complication free!