JAN-D-5
A FULL OPERATING DAY AT LBH,
BEGINNING WITH A PRE-DAWN RUN TO MATAPAY,
AND A MORNING FULL OF THYROIDECTOMIES AND OPD CLINIC
WITH A TROPICAL RAINSTORM AS A VAGINAL HYSTERECTOMY
FOR STAGE IV UTERINE PROLAPSE,
PRECEDES A LATE DINNER INVITATION TO THE LBS—
THEN, THE SOCIAL PLANS ARE DISRUPTED BY A SEQUENCE OF PATIENT
EMERGENCY ADMISSIONS—STROKES AND “LOCKJAW!”
January 27, 2003
I had promised myself that a full day should begin with a pre-dawn run to Matapay along the river whose name was unknown to everyone I had previously asked. The long term OR nurse, Ermina, trained by Dr. Lincoln Nelson twenty years ago, lives along the river and asked its name, reported that it was the “Solod River”. I would have felt better about this if I did not subsequently learn that “solod” means “river,” but upon return to check with her, Ermina. Yes, the river is named the “River River.”
I was alone and ran down the path that goes to the sea, where I passed the drying floors for Copra, the coconut meat that is dried to a pulp—the Philippines number one export product, which goes into everything from soaps to paints to some foodstuffs. The same drying floors are used for rice, or cassava, but the poorer people not associated with a cooperative buying and foreign marketing service use the roads as a place to winnow and dry their grains, and rake up whatever they can salvage after the traffic goes through.
I ran down to the sea, as calm as glass, and saw people stretched in their hammocks in thief “front porches,” next to the net drying platforms, of their bamboo huts on stilts. It looks picturesque, even if less than waterproof from rains and floods, and open to soothing sea breezes. Almost like the tarpaper shacks of South American barrios, out of a small hovel in the mud a “chrysalis-type” transformation will occur, and a perky young lady will emerge in a white clean and pressed dress to walk down the pathway between piles of coconut husks and trash. Three small gamins were walking in the shallows of the “Solod River” as it met the Philippine Sea, in what I have learned since yesterday is called the “Canigao Channel,” with one, about four carrying the other two nudeniks as they dangled for their morning ablutions. It was a good run.
When rumors of my early running have passed around, there is a local outreach pastor, Lantao, who is keen that I run the other way toward his village named Bato, to see his new church, which is 7 km in the opposite direction, making only 15 km round trip. Will he run with me? “Oh, know, I will meet you at 5:15 AM, and I will ride my motorbike each way while you run to Bato and back.” So, I have this final run to look forward to tomorrow, with an escort. Jasper, my senior nursing student Tacloban, has been packed off to bed with a fever since he tried to run with me on Sunday morning, when he could not believe I had first intended, and then actually carried out a run of more than a kilometer. “But, you told me he was over sixty years old!” he had complained later to Dr. Bahby when he had taken to his bed stiff and sore.
THE ADVANCE TEAM SCOUTING REPORT ON THE CAPABILITY
OF LBH TO HOST A SURGICAL VISIT
It works, and wonderfully well! The OR’s are capacious, well-equipped with equipment that may appear to be obsolete, but all of it functions, and they have adequate suture and supplies to do most any procedure that would be listed for such a mission. I rather enjoyed it. Especially being my own anesthesiologist, using 0.5 mg of IV Stadol, followed by 3 mg of IV Diazepam combined with highly effective cervical region local anesthetic blocks more than adequately covered the three thyroid operations, without any need for supplemental local or systemic anesthetic agents. Each was carried out smoothly and safely, with good results.
I did the first thyroidectomy with Dr. Ragon and the second with Dr. Bahby, each of which went well. Between cases, I went to clinic and saw about forty patients in about forty five minutes, a number of whom we scheduled for minor operations or treated with medicines for longer term treatments. I had seen the upstate New York old school influence of mission medicine in the design and carrying out of the structure and function of the 16-bed hospital with all of its component parts familiar from American mission hospitals I have seen before, especially recognizable in their nursing policies and procedures. I was fed well at intervals by people who were concenreed that I would be famished if I went for two consecutive cases without a break and a snack. I saw the post-ops who were doing fine and look like they will be going home tomorrow. It seems that the 50 pesos for “full bed and board” charges in the hospital ($1.00 per day) is still too steep for many patients, so there is a facility like the “Kohler Hotel at Mayo Clinic” next door where there is a boarding facility for patients who cannot afford the full fare, and rent a 5 peso per day (10 cents US) room with family, cooking facilities and a “C. R.” This is a Philippine regular term, akin to the British “W. C.” (for “Water Closet.”) which here stands for “Comfort Room.”
Even then, the LBH, which must subsist on the collections of its revenues, is hard pressed to make ends meet, and the very large outlays of cash from its resources to meet some licensure requirements. One of these was that it had to have a NICU (“newborn intensive care unit”) to be a secondary hospital. That was easy enough: they hung a sign over one room. But the next was harder. They had to have an anesthesia machine to do elective operations. They had to purchase it out of their own funds, and the new machine costs 12,000 US $, against the ten US cents a day from the boarders in the house across the way on the revenue side. But, they have it now, and they are still designated a secondary hospital.
When the two hectares on which the hospital and the outbuildings for it were bought from two brothers adjacent to their sisters’ houses, the elder brother sold it and the second brother was signatory to it. Now, with the older brother dead, the second brother has vacated the title, and wants half of it back—the half on which the school and church are standing. The judge yesterday said he had known about this case since he was a young man, and here it was still dragging on. Isn’t this the signature at the agreement of sale of the younger brother now contesting the terms? He gave two months for the complaining brother to come up with proof that he is entitled or pay all the court costs in this frivolous suit. Now where are judges like this when I might need them?
We then did a Cistrunck operation for a large thyroglossal duct cyst (TGDC). The key is resection of the midpoint of the hyoid bone, and this was carried out successfully and well, again under the cervical block anesthesia.
The last case was the older woman with the very pronounced uterine prolapse, and this was going to be a vaginal hysterectomy that Bhaby was going to do. The anatomy was certainly distorted by the severe prolapse, but I had worried in advance that the ulcers on the prolapsed uterus might represent cancer. Bhaby struggled for a while to find the uterine arteries and get into the peritoneum, but then, she got around the very messy big specimen and was about to take it off, when she encountered a cystic kind of structure into the bladder and encased by a gritty cartilaginous part of the specimen. It turns out that the tubular structure is the ureters, and it was encased in—I had guessed it—the invading cancer all around it. So, the dissection had to include the debulking of the tumor and skeletonizing the ureters to leave it intact at its entry to the bladder. So, this woman has had remarkable relief, even if the operation took twice as long as the spinal anesthesia had lasted and the patient needed to be supplemented with IV anesthesia. Bhaby had asked whether I was going to scrub in and take over in the reconstruction of the floor of the pelvis and identify the confusing structures there, but I did not want the staff to think I had bailed out a gynecologist who was doing a very competent job of a very complex case, so I stood watching and consulting and encouraging.
CAN YOU BELIEVE WHAT HAS COME IN NEXT?
Meanwhile, however, I also had a very interesting patient coming in to become even more fascinating. A young man about 18 years old had been brought by pump boat to a town and then by government ambulance (the LBH ambulance is being repaired from the accident it had on the night we were in Tboli, in which a patient was being transferred and a drunk weaving in the road on his bicycle was struck and killed instantly, and it still has no windshield and had to be pushed in out of the rain to avoid getting filled with water.) The young man had an unusual complaint: he had dislocated his jaw. Not once, but repeatedly this evening since he began having spasms and stiff muscles. He had a history that he had been bit by a dog ten years ago, but no recent punctures of any kind. He had never dislocated his jaw before, but it had popped out, and then had come back in after a series of spasms had subsided. We were going to give him Ketamine to reduce the jaw and then found it was reduced. Then he went into a grimace, and the jaw popped back out on the left TM Joint. Curious—where might I have seen that kind of look on the face before?
The next thing that was remarkable is that he had a strong series of spasms, that made all of his muscles tight, but particularly his leg muscles and then his back muscles, and gradually he had them pull him up and over backwards. Ahah! This I recognize also—it is opisthotonus! And what would that jaw-clenching tight spasm be called in his face at the same time? “Risor Sardonicus!” Put the two together along with the old name---“Lockjaw”—and what conclusion can we draw—he has tetanus!
Now just how often does one make a diagnosis of tetanus in the US? I saw it once, in a farmer referred to the UMMC because it was such a rare and unusual case. Then I saw it again in Nigeria, in all instances fatal, and most often as tetanus neonatorum. Now there are only 100 cases a year in the US because of nearly universal tetanus toxoid inoculation. There are 100 cases an hour in Africa, almost always under-reported since most are simply deaths of children and other sin mysterious circumstances. So, we cranked up the treatment with O2, 20,000 units of Penicillin G, and IV Diazepam. But the hard part was in getting the tetanus antitoxin to him, which by rare good fortune the LGH just happens to have. But 5,000 units of antitoxin which the Current Therapy recommended would cost the family more than they can collectively come up with by selling everything they have. Still more fortunately, there is a foundation they knew about that would support him if it were given, and, on faith, it was given to him. He already looked better when I came back from checking Bhaby’s closure over a film pack (a five yard roll with an incise drape making a “dam” for a pelvic floor support and a hemostatic tampon.
Then Ragon admitted an older woman who was a known hypertensive on therapy who had suddenly reported a headache, and fell over, now in decorticate posturing with a stroke. She no doubt has an intracranial bleed, and cannot last long, despite the steroids, mannitol and antihypertensives he had started for her, This is the third intracranial catastrophe this weekend we have seen, and each appear to be related to hypertension and two of the three are already fatal,
So, here we have done a full day's elective cases and done them well, including a very complicated gynecologic oncology case. Yet, we have also admitted some fascinating unusual cases seen only uncommonly in the non-tropical setting. There is still rabies here, and a few patients have had this lethal condition and were seen in LBH, which was an early part of the differential diagnosis—a thought that made me feel uncomfortable when I walked over to my Guest Hose room and was swooped over by repeated passes by a bat. But, we were busy and doing what we could, and as much as anyone could anywhere.
Only one family might be unhappy with our work—that is the family of Leyte Baptist Seminary superintendent, the Hoppers, who were expecting us for dinner four hours ago, when we called it off, and had a rapidly fixed ten thirty dinner with the Espina household. OK, our social life has been disappointing to some, but our medical professional life had been more than rewarding!