JAN-B-7
A HIGH VOLUME TUMULTUOUS OR DAY WITH LARGE
NUMBERS OF DIFFICULT,
YET
SUCCESSFULLY DONE, CASES, AND THE GENEROUS “LECHON” FEAST
AND FAREWELL CEREMONY,
BEFORE PART OF OUR TEAM FROM BUKIDNON PACKS
UP
SOME OF THE HEAVY SUPPLIES AND MAKES THEIR WAY BY ROAD
BACK TOWARD MALAYBALAY AND BBH
January 16, 2003
What a high volume day of heavy duty surgical caseload! While we were working hard and fast with outcomes that surprise anyone who has ever attempted to “push the envelope” in the number and intensity of the surgical volume that can be produced, somehow—just, somehow!—the patients were all doing well, and the recovery room was emptying out of the crowd of post-op patients we were delivering there at such a high rate when the team who had been out busily preparing as we were still operating began the festival of feasting and grateful thanks in their emotional “Farewell” ceremony.
That is not to say, since we have said our farewells, that we are through, since we have a full day of operating yet to do on our final day tomorrow, but that will be taken on with a reduced staff and much of the borrowed equipment packed up and on its way back to BBH in Malaybalay, where we will rendezvous with them by air for the next one week phase of our medical mission to Mindanao.
THE MORNING’S OR CASES MIGHT HAVE STARTED WITH A CASE
OF MISTAKEN IDENTITY
In my rapid consultation review of the pre-operative surgical cases in clinic yesterday, I had seen a small baby with and epigastric hernia, and scheduled her for repair, which Alan had put first thing in one of the three tables, the one anesthesiologist Don is so capably handling. He does well with small children. Outside in the courtyard where the pre-op patients are stacked up awaiting their cal to come in, with their IV’s already started and their necks prepped sat two patients, one a man with a large goiter and a grossly distended set of neck veins which extended all the way down his right arm and across his chest. I know what that means, and called him the “goiter plunge’” using the French term that I had used with Charles Proye in Lille, France when I had operated there in his busy endocrine surgical service. The second adult patient was a woman with a parotid gland tumor, extending down the tail of the parotid gland. There were two babies also out there with IV’s and the first was brought into the room where Ragon Espina and I would be operating. Alan had put the epigastric hernia baby first, so I can in and felt the upper abdomen as Don had induced the child and intubated. Strange, I thought it was a baby girl. I could not identify the epigastric hernia, whereas I had felt it prominently before when I scheduled the patient yesterday. Ragon came over to see the patient for the first time and we found a hydrocele in this little boy. We looked again outside and did not find a little girl, but now also saw the policeman’s older father with a large right inguinal hernia, that Ragon had chosen out of the list we had postponed to Friday since he had wanted to se my technique of fixing big hernias under local anesthesia in an outpatient, sine that is the way he will have to be operating when he returns to Leyte to the LBH (Leyte Baptist Hospital). I had told him that I can mix 1% lidocaine with 1:100,000 epinephrine with ½% marcaine (bupivicane) to make a final solution of ½% lidocaine with 1:200,000 epinephrine and ¼% marcaine for both short-term anesthesia and long term analgesia in adult hernia repairs, and he was eager to try it.
We returned to the OR and said, well, the one thing we see here is a hydroceles and “patent processus vaginalis” –a latent hernia, in this young baby boy, so let’s fix that since we are already ready under general anesthesia. We did so. Only later did Dr. Bing come in to ask if we had seen the baby boy she had sent over with the hydrocele hernia, since the baby girl with the epigastric hernia had been breast fed at three o’clock AM and she just gave her a wider safety margin. So, we did the right sequence of operations on the wrong sequence of patients, a far better result than the reverse, a likely possibility in a full speed ahead high volume surgical “factory” of the kind we are pushing hard. We then did the adult hernia, as the big goiter and parotid patients sat patiently, with one of the younger women goiters moved in for Alan to operate on, a move he immediately said should have been sent to me, since the young woman’s goiter was sticky, bloody and adherent to things around it, a likely sign of a malignancy.
Ragon and I did a “Moslem hernia” in an older man with a Moslem cap—I tried to convince them that the Moslem hernia was indistinguishable from a Christian or pagan hernia, but this being Tboli Evangelical Clinic and Hospital; they have their own way of primarily identifying patients. I had another way still. There was an old man with a straggly white beard (only a few hairs from his chin may be a too generous way of describing him as “bearded”) but that may have been the reason he identified with me. We fixed his hernia, and he was very grateful, having come a long way from the deep interior mountains. Only later was he identified for me as the “Tasaday patient”—a second time I have operated on the last residual stone age civilization members left on Planet Earth. Here was not just an old man, but the cultural prototypical ancestor of all of us now living on this rather crowded planet. .
I went to clinic between cases, as they wanted to postpone the big goiter and parotid cases until the afternoon after lunch. There I saw a recurrent Baker’s Cyst in a young child, and a mucocele, which I drained immediately on the spot in a young woman’s mouth. A few more goiters had come in and a couple of hydroceles. Then, they said, “You will recognize this patient!” In came a woman so frail she was half carried by her family but they had to turn her sideways through the door because of the huge girth of her distended abdomen. She had such tense ascites that she could neither breathe nor lie down flat, since the pressure was impeding her venous return through her vena cava. So, as I had last year in our final case before departure, I made a small incision in her tense abdomen and fed in an IV catheter for a paracentesis, and drained her into a large wash basin. When I h ad returned they had changed that basin over six times, meaning we reduced this woman’s weight by well over half, so that she could both breathe and lie on her back. Today we will examine the underlying cause of this problem and see if any correction is possible, since we had made a “one stitch cure” of the huge ovarian cysts last year, both her and in BBH at Malaybalay.
We had the good Filipino lunch we have been pampered with by a whole separate crew that is all supported by the special project fee ($1,000) we each contribute to support the patients and t her helpers, their transport, lodging and food when brought here, and our own support staff. I also took a picture of the woman stoking the outdoor autoclave, a pressure cooker over burning charcoaled coconut husks, as we endlessly recycled the “one time use only—disposable gowns” I had brought as part of our packing up the supplies in Derwood.
AN AFTERNOON OF HEROIC EFFORTS AT FIXING
BIG GOITERS
I turned away only one patient—a woman with a large necklace goiter that was solidly stuck to all parts of her neck, and which seemed to be rapidly growing despite the Lipiodal injection. Ten months ago it was not there, a history confirmed three times with others. This means that it is the malignant kind that is not only incurable but also untreatable—anaplastic carcinoma, neither in the Philippines nor in the USA is ANY treatment efficacious, and all we might do is make of her a surgical death rather than a slow demise and asphyxiation. There were several others of large proportions and one was presented for the first after noon case. The man who had sat there so patiently all morning with the large goiter and the grossly distended neck, chest and arm veins, is now on the OR table for mew and Ragon to fix. I explained that, like the submarine part of the iceberg, the majority of this “goiter plunge’” was in the patient’s chest, and this mediastinal component had occluded the superior vena cava which is why this large and tense veins were seen as an indication of this. It would not be easy, it could be very bloody, and it would take a very heroic maneuver to deliver this large intrathoracic part up into the neck in order to attempt to get control of these very large veins, which would be very fragile and full of high pressure high volume blood flow. Everyone ready?
Even the skin incision bled a lot. We tried to avoid veins the size of our thumbs as we exposed the big gland and saw that it “dived” (”plunge’”) down into the chest where the majority of this beery sold mass was resident. With the suction filing the suction bottle rapidly, we had only about two minutes to attempt to fix this problem before the patient would be in shock, so I got each of us ready, and reached around lateral to medial and dissected with my finger down deep into the chest until my fingers encountered the pulsating innominate artery, the second largest artery in the body. I teased the gland’s lower pole away from these great vessels, and pulled the large submanubrial extension of this large goiter out of the chest in a swift delivery and stuffed a lap pad down into the chest on the pleural dome I had exposed. The sucker went quiet, and Ragon was impressed. We went from a life threatening condition of certain hemorrhagic death to a calm removal of a controlled isolated specimen within the minute and no more blood was lost after the goiter had been delivered and the great vessels feeding it were clamped and suture ligated. Thank you Lord, again, for the outcome, not under our control. This patient did very well, and immediately post-op, the very big distended viands all over his chest arms and neck were no where to be seen.
Then, we did it again. This time Ragon was up front, and confidently delivered the gland for control of the bleeding. “Now, how will I do this under local anesthesia without any help in Leyte?” he asked. That is a reasonable question, and I asked it many time in extremis in Zaire in a thatched hut!
We then did a young girl who seemed not to have that much size to her goiter, but she was very symptomatic. The reason was soon apparent. The rubbery mass of the goiter had extended all the way around the posterior part of her trachea and esophagus, and had to be pulled forward from its insinuation between these structures which it had no doubt been blocking for years.
In between these cases, I had brought over a young fellow who cold not bring down his arm because of a large lipoma along his back and armpit. I had him walk into the OR, and with only 3 ½ cc’s of Lidocaine local anesthesia injected superficially in the skin, I dissected out this large rubbery lipoma, and popped it out like a football, giving him this souvenir to carry home before his incredulous eyes.
A young man who might represent the opposite in pain tolerance had a mass in the lymph nodes along the left side of his neck, and I aspirated it yesterday, getting nothing in the yield from this procedure, so I said I would do him under local anesthesia with sedation, while Ragon started another thyroid. He had passed out at the start of his IV. He was almost unable to view the world from the covers he draped over his face so that he would not see what was going on around him in this shop of horrors where there were men from far away working diligently on dismembering people while they were still alive. With short acting sedation and a little local, he became one of them. Only eleven minutes later, his large mass was stripped out of his neck, and his closure was started by me, and finished by the all purpose utility outfielder, Al, the one single person without whom this mission could not be done.
Alan was having a tough time with the parotid, in identifying the facial nerve, and was just praying that it would come out all right as he dissected around it and buried stitches where it should be. As with out other patients, by the grace of God more than the skill or temerity of the surgeons, this patient, and all the others, were doing well, with smiles and grateful rapid recoveries by the time we popped one patient out of the recovery room beds to refill it with another.
A woman came to me with remarkable asymmetry of her breasts—the right very much enlarged but non-tender, with a rubbery firm mass in it that could be polycystic, but it is not nodular nor tender and does not change with her menstrual cycle. In another world, we might know from mammography whether there is suspicious calcification in it. I would tend to remove the area of the mass since she seems quite curable. Already tomorrow we are doing a mastectomy called a “toilet mastectomy” to cleanup the fungating cauliflower mass on the chest of the pastor who has recurrent cancer whose biopsy from Tuesday has returned nasty infiltrating cancer. The “submandibular mass” which was said to be salivary has also retuned from the Gen San pathologist as papillary thyroid cancer.
We have a kidney tumor with IVP and ultrasound showing a mass, and a functioning opposite kidney for whom we should do a radical nephrectomy.
The last minute case that appeared was from a woman doctor whose sister had a bizarre finding. Only five days ago, age 33, she had discovered a mass in her abdomen, which on CT which her sister had arranged for her turns out to be a fusiform aneurysm from the descending aorta’s origin to the bifurcation of the iliacs—at 33 years old! This must be some special circumstance, since she would have no evidence of atherosclerosis and the other problems to which fat rich older Americans are prone. Further more it is 11 cm in its greatest diameter, and she is hypertensive (renovascular hypertension, so it may be a dissecting aneurysm.) It turns out that this kind of mega-problem would require lots of blood, open heart teams, and all that the third world does NOT represent. Now where in the island of Mindanao can she be treated, which they already proved by going to the biggest city, Davao, and being rejected. I then remembered that George Garcia, Philippine born cardiac surgeon at Washington Hospital has opened a cardiac hospital in Manila and his team comes over to do the rich Philippines in the capital. I wrote a note on my cared, and asked, as a colleague, that he might be charitably disposed toward looking in on this interesting case, and do what ever is necessary to correct the problem,. The patient and her sister will take the CT scan and my card and letter of introduction to Manila. I wish them well---and soon!
THERE’S A PARTY GOING ON!
While we were still carving in OR, a whole team was carving on the Lechon--the roast young pig. It had to be bigger than what the Spanish call “Lechon de Leche” (suckling piglet”) since our feast had to feed all the staff and the security troops and some of the patients and their support staff. But we had the dinner, and then moved into the big building “multi-purpose room” the place where the long-distance patients and their families sleep and the guards are stationed, and they had the songfest, and brief statements of the team as a Farewell Ceremony. I saw the woman with the huge goiter whom I had declined since she is inoperable and incurable very prominently in the front row and singing along with the rest joining in the grateful celebration despite her disappointment at not being operated on like the others she can see around her. I gave a brief speech (recorded, as were all the others) emphasizing the trust and inspiration from the patients, including those we may not have been able to help. They all wanted to stay for photos.
A young woman came from a long way away and ran at me to collide in a hug. The sign of extreme respect in the Tboli culture is to grasp my hand in both theirs and to touch it to their forehead. This had happened to me from multiple post-op patients I had seen whom I had treated last year, but this one was special. It was Josephine—now a young g woman. She is the young girl who had total destruction of the midface. We had declined to try to start with a multi-stage reconstruction here, and I had carried her X-Rays back to Operation Smile, but never heard anything from my request to Bill Magee, Op Smile’s founder. We had carried her to BBH at Malaybalay last year where the woman plastic surgeon began her first stage of reconstruction, closing the mucus fistula in her mid-face. She still does not have a nose, and now will be going back with us by ambulance from TECH to BBH along with her family and the other three patients who were brought up for multi-stage reconstruction this year. Josephine looks so much better than the earlier photos I have carried of her, that I do not think she even needs to see them.
It is late. The team is exhausted, and half of them are going to be on their way at 4:30 AM in the already packed up vehicles. The rest of us will be undertaking eleven more cases tomorrow, and who knows how many walk-in patients who are urgent. It has been another surgical intensive marathon in TECH among the grateful Tboli!