OUR SECOND CLINICAL DAY AT LBH,
AFTER AN EVENTFUL OPERATING DAY ON Monday, January 27, 2003
FURTHER TESTING THE CAPACITIES OF THE FACILITIES AND STAFF
TO HOST A SURGICAL MISSION
January 28, 2003
AN EARLY RUN IN THE OPPOSITE DIRECTION TO BATO
Pastor Lantao was right on time. I had been too early, since all the roosters and guinea fowl cut loose at 3:00 AM when two things had happened to occasion a disturbance outside the house. The nurses called Ragon because the old woman who had had a stroke and was in decorticate posturing had to be intubated, and then went on to die of an expanding bleeding in her head. Also a child was admitted with dengue fever, and all that is done for that is supportive care. But, I thought that the fowl had sensed the coming of dawn after a heavy tropical rain earlier, and had broken into the chorus that was to have been my alarm clock—although almost anything is more melodious than the rusty hinge sound of the guinea fowl’s squawk.
I came out at 5:30 dressed in running shorts and tee shirt, probably still overdressed for the ambient temperature at that time, though Lantao was wearing the same kind of knit pull over cap and heavy shirt that Jasper had worn when he had come to see me at a similar hour on Sunday morning. It is cool here at this time, was the obvious message—but maybe only if riding a fast moving motorbike. I took off with my watch marking the time, as Lantao rode his motorbike ahead of me, or alongside. There was little traffic, and only once or twice did I see people looking very sleepy rolling out of the hammocks strung in the platforms of their bamboo houses to look at me. They inevitably smiled at the view of someone needlessly exerting himself, and approved that Lantao had the better sense to be on his motor bike.
We went passed the rice paddies of the Barangay Sto. Maria, from which beach we had taken the “pump boat” on Sunday afternoon through the Canigao Channel to the lighthouse island of the same name. The administrator of the clinic has a husband who is the “captain of this barangay (read as “precinct captain”) and the driver of the boat was the fellow who knows all the e pedicabs drivers and fishermen by their blood types. For a type O, a fast 700 pesos can be achieved, so that beats pumping passengers through the torrid humid heat. We crossed a bridge that I read in passing as the Tarangas Bridge, with a date of 2000, while the next one. Also over a palm-fringed brackish water river toward the ocean with outrigger “pump boats” tied up along the palms was labeled something like Tarakhoran Bridge with the date 2001. This is obvious “ward-healing” for the benefit of the Barangay and the popularity of the incumbent government through the doling out of public works projects, but it works for a runway for me as well. I saw multiple sites of the small barrios after I had run out of the city limits of Ilhongos on the other side of town from the Matapay side I had used last run, so I have covered the long dimensions of Hilongos. I followed Lantao until we came to the Assembly of God church, where he left his motorbike just outside the city limits of Bato, six kilometers into my run, since he wanted to run in with me. He did—until a friend in passing pedicabs tricycle happened by and I next saw him hanging on the back of the pedicabs as it passed me.
We went under a banner announcing the Miss Teen Bato contest sponsored b y the Bureau of Fisheries, for which I saw a few likely candidates. Young women have the languid casual beauty of youth in the tropics, but age rapidly with multiple childbirths and other harder knocks of life in the limited opportunities of the island of fishing boats and limited education. I passed several public works buildings and the “old town” all of them spelled out in Tagalog, a language no one speaks here since it is the language of the north, but that is where the central government is that doles out the favors. I turned left away from the Bato Rock, which is the site the fishing boats tie up to and went to the still building Fundamental Baptist church, passing the Bible Baptist church—a species not too far removed but also with its own administration and schools etc.
When I slowed to make the turn into the street where the church is, we passed to men and a small crowd, even this early n the morning, with the two men holding fighting cocks with long steel spurs strapped to their legs. They released them with a flourish, and the cocks tore into each other. When they saw a white man with a camera, they nodded and wanted to repeat this flailing of wings and spurs and snapping heads. So, I shot the last exposure in the camera, although I had carried a spare roll with me to reload when I sat for the first time in the church and saw the officers of the church, including advisor, Mrs. Lantao, whom I subsequently met. He told me about the campaign they had to complete the church, which sounded very cheap to do, so he asked for the prayer support of my friends. Since the prayers of the righteous availeth much, I offered to have my sisters look into this win their groups and when he produced an envelope and letter, I addressed it to Shirl, adding a letter later and a few other notes to mail from Leyte, where a special motorbike dispatch was made to carry the letter to the post office with my pesos to frank or stamp it.
I made it back as the sun came up and it got very hot. I passed a coffin maker and an empty coffin was loaded onto a tricycle pedicab to make the trip back toward LBH. I took a picture saying that one could ride dead or alive in a pedicab, with the comfort factor much greater in the latter condition, but I was corrected. The pedicabs driver would never carry a body since it would bring bad luck. When a child dies at the LBH, the parents wrap it up in a blanket and carry it in their arms talking to it, since if the pedicabs driver realizes they are carrying a body they will not stop to pick them up. Later the pedicabs with the coffin came to the LBH, since the woman who had been talking and eating dinner when she fell over with decorticate posturing and was admitted last night in the middle of the excitement of the completion of the malignant resection of the vaginal hysterectomy , originally started out as a severe prolapse of the uterus, and the “lockjaw” patient, had been given mannitol and steroids and an anti-hypertensive to lower her blood pressure, had continued to hemorrhage into her head and rapidly dies after the intubation that Ragon was called to do last night. At noon today, I saw the coffin used to load the woman’s body on the back of a pickup truck while the family began to process behind it to walk out of the hospital grounds toward the funeral. A few umbrellas were unfurled as a rain storm hit with a saturation of the mourners parade.
THE CLINICAL DAY IN LBH,
COMPLETING THE OR CASES AND MAKING ROUNDS ON THE POST-OP PATIENTS
The patients are doing extraordinarily well. All the thyroidectomies had their wounds redressed and drains removed. Each was eating and ready for discharge, including the man with the TGDC whose central hyoid had been resected in the “Cistrunck operation.” The woman who had the big operation for the severe prolapse that turns out to be malignant in the vaginal hysterectomy was surprisingly chipper, and eating. But, most amazing of all was the young man who had been brought over by “pump boat” from an outer island with the recurrently dislocated jaw, who tuned out to have big and bad muscle spasms, and went into the pattern of “opisthotonus and risor sardonicus”, which can be none other than tetanus, even if he had no obvious wound. So, we treated him as tetanus, with 20,000 units of Penicillin G and IV diazepam for the spasms and the tetanus antitoxin to the extent they could work out the payment for this expensive product. As we saw him this morning, his jaw was relocated; he had no muscle spasms, was breathing normally, had no evident risor or opisthotonus, and looked like he never had had a problem. He would be immediate grand rounds presentation material anywhere in the US where there are fewer than 100 cases of tetanus a year. But, he would have been ignored in Africa where there are 100 cases an hour and even that is under-reported, almost all of them fatal. So, our “Lockjaw” is unlocked also!
We began doing the minor cases we had seen yesterday, including the young school girl who had a draining sinus fistula in her neck since birth. Her mother is a sophisticated consumer and had asked if there were a pediatric surgeon coming who could look at her child. We looked and confirmed that it is a pharyngeal sinus tract, no doubt a congenital abnormality, and set about fixing it. Dr. Ragon Espina did a very careful and superb job. When I came out with the patient (a VIP enough to warrant the A/C room) the mother thanked me several times. I responded, “Yes, and he did a superb job of fixing this, too” making sure she and all others knew that it was their own Regan Espina who had done it.
We also did a woman who had had a neck mass for three years—it could have been a TB (“caseous granuloma”) or a neoplasm like a lymphoma. There were two large and firm nodules in her supraclavicular space. I suggested the “Rule of Sevens” with a neck mass”. “Seven Days = Inflammatory; Seven Months = Neoplastic; Seven Years = Congenital,” and suggested that this one was likely to be neoplastic. Sure enough, when the walnut size node came out, we touch-prepped the cut edge for cytology and sent the rest for histology, which will probably show it to be a lymphoma, for which treatment facilities will almost certainly require her transfer to a big city like Cebu City.
We saw a three year old boy with an inguinal hernia. He was very well-behaved. We suggested that we could start an IV and not feed him until the afternoon when we could do him under the “dissociative anesthetic” of Ketamine—which he laid quietly and looked all around with big eyes not making any moves or sounds. Most US kids would not be able to be restrained under similar circumstances. I suggested that our “pediatric surgeon”, once again, had done a good job!
I scrambled back to pack up and to write a little charging through a very brisk warm downpour. As soon as I arrived, I was whisked away again this time on a “postponed visit.” The Hoppers who had been disappointed last night were not even phased in the least when a call today as we made our apologies—“Why not come on over right now—we certainly have a lot of good leftovers from the dinner you did not have last night!”
So, we drove through the heavy rain for 65 km to Maasi (the name means “Salty”) the capital of the new province of South Leyte—only two years old and some politician’s way of getting elected a supernumerary congressman, We had a good dinner, heard that the Tamp Bay Buccaneers—a former NFL laughing stock –had won the Super Bowl, and that tonight was the State of the Union message for GWB who has just heard the further bad news that the Iraqis have sequestered further weapons of Mass Destruction and now must do something further about them. What else I learned can be put together on the long return trip tomorrow starting at takeoff 6:00 AM from LBH and going through the sights of Leyte to arrive at our first flight from Tacloban to Manila to catch our long flight home.