06-JAN-B-5
THE SURGICAL
WORK LOAD OF CASES AT TIBOLI TECH AND THE CLIMAX CELEBRATION OF MY BIRTHDAY IN
THE FAREWELL CEREMONY FOLLOWED BY BIRTHDAY CAKE AND UBE ICE CREAM AS WE PACK UP
TO
January 19—20, 2006
I awoke early at the mission long house in Edwards and decided I would walk in my scrub suit on my birthday morning down the dirt path to the road to go in early to check on my post op patients before our fruit-laden breakfast. I walked out just at dawn behind two boys leading a large white zebu bull out to picket for a grazing spot as they would be off to school later that day. The first ritual is as old as time here in South Cotabato, but the part about school would have started with the arrival of the likes of such stalwarts as Vivien Forsburg and Ethel Moorhouse, before whose arrival there was no road, let alone a paved stretch of it. The paving is a gift from the Americans at around the time I first arrived here now almost a decade ago. I walked along that road between fields hand cultivated with pineapples, sugarcane and corn with the volcanic rugged peaks behind them—the mountain fastnesses from which the Tasaday and Tiboli people come to me on foot after several days walk to get to the road head here which allows them and family care-givers to be picked up by the TLDF (Tribal Leaders Development Foundation) truck. It has all changed to “second world” status even during my brief tenure here, with electricity and even (although not during our stay!) running, even hot water! So, it must be an even greater transformation for those who are veterans of this field who came before there was a codified spoken word and wrote Bibles, dictionaries and established schools and literacy programs. Wuaneng Dagang, the first (and still the last) Tiboli to have gone to school under Ethel Moorhouse’s sponsorship, has been very capable at the kinds of community organizing that has made these social programs possible. It was a longer term perspective I had during my walk that made the longer view on my own life possible.
When I was born
there were Americans aware of this area all right. One of them, Captain Parker flew into the
nearby mountain, a Tiboli landmark, as he was searching for Japanese occupiers
to root out. There was a war going on, a
war that had brought the
Not many of my post op patients were there. Why? They had got what they came for and were on their way home! A few goiter patients were still there, with a small neat dressing replacing the larger post-op one they had on at the conclusion of the operation, with their drains pulled and their voices and twitches checked. Two were singing. The others including the patient with the large duodenal tumor that had spread through the retroperitoneum and who had a blood loss requiring a several unit transfusion---meaning the staff had each lined up and donated a unit of fresh blood—were doing well. A surprise of the kind that must happen when an apparition of one dead some time re-appears came to me the day before. A stately woman walked up and took my hand placing it on her own forehead, a mark of extreme respect. I did not recognize her, but she surely knew me and the others—Mrs. Rodriquez. This is the woman who had a hepatoma, with several nodules in her liver resected last year, and post-op bleeding which made it very unlikely she could survive. Her BP had faded to nothing and her temperature had also dropped very low. Bags of rice were made by tying up rice in socks, and putting the dry rice bags in the oven and stacking them around her. Alan Mellicor did the third reparation and not only stopped the bleeding but also resected the last of several liver nodules of the malignancy. We had to transfer her to a hospital when we left Tiboli last year with not a lot of long term hope for her. But, here she was, with songs of praise and thanks, a genuine resurrection in the flesh. We posed with her to have pictures to remind us that we are not the ones most active in determining the fate of those we deal with, but that this is more grace than skill. It seems that even the “long reach” patient for whom we have tried a bit of palliation to help them heave done well, and despite a burden of disease which would have been lethal for anyone in a developed world situation, here they return smiling and grateful. And you wonder why I am back here on my birthday?
TALLYING UP THE TIBOLI PATIENTS
AND OPERATING ON THE LAST ONES,
EVEN AS THE SURGICAL KITS ANG GEAR ARE
BEING PACKED
I did several goiters including one very cute wizened older woman who also had large non-tender parotid glands. She was so grateful, that without a word to express her fear before the operation and her joy after it, she simply reached up and touched my hand before and after and smiled. I did several more, and then had two “male patient goiters” to be done right after lunch. I have always gone to see the patients before doing them, and that has often resulted in surprises—such as a hydrocele advertised as a young patient with an acquired hydrocele having an indirect inguinal hernia, or last year, a large solid hydrocele, not transluminating being a large malignant testicular tumor—a seminoma. The different diagnosis means a different approach for different purposes—groin versus scrotum in these examples—and so it pays to check on what has been sent under a diagnosis not of my own making. Today it was a young man with an “ectopic goiter”. It was ectopic all right. It was a solid mobile tumor lying under the angle of the left jaw. Just exactly like last year, he presented me with a submandibular gland malignancy, and a case to be done that involved a radical neck dissection “supra-omohyoid” meaning that it was limited to the upper neck, blocking out the submandibular gland and the firm mobile tumor within the bloc dissection. It was slick smooth and easy, the kind of operation that should have been made into a movie about how easy it would be to do this kind of operation. Last year the young woman I had done here with this kind of tumor was on her way home in the morning with a big smile. I then took Monique Hopkinson to the next patient since we were posted to be doing a goiter together, and the next patient was an alleged small goiter.
Not so. It was a thyroid cancer stuck to the skin and invading through and replacing the strap muscles and stuck all along the lateral sides where the vital structures of the recurrent laryngeal nerves and parathyroid live. We did a “damage limitation” operation, clearing the massive disease off her trachea without entering it, and staying away from the potential complicating areas at the entry of the nerves into the larynx. We did what we could and accomplished a rather rapid operation with a clean out of gross disease, but, importantly, without complication of entry into her airway or sacrifice of her voice or calcium balance. After it was over, I asked her “Which operation made her feel better about what she was doing and which would be more memorable for her? Was it the slick and smooth submandibular resection with a radical neck dissection, or the taxing and difficult damage-limiting cancer stuck to everything vital?” She answered, of course, that the one that went so well was the one she would remember. “No,” I replied: “Anyone can do the procedure that goes so well that it is hardy a challenge—the one that only you could have pulled off so well on a patient so trying as this last one is the one that is a test of your skill and judgment.”
We had to finish as the tools were being packed and ALL of the stuff I had brought, including my Gomco suction unit and the other surgical supplies were being left here, so that I am carrying back the empty black bags to pack up fully for Rwanda with the stock of material in the Mission Room in the Derwood basement. I went over to change clothes form scrub suit to the kind of clothes for their special celebration that evening and you can guess the rest.
Two years ago
I had a birthday that was celebrated at Malaybalay in
When the Tiboli graceful dancers came out in costume, they—of course—picked me to dance with them. I got into it in such a way that made the whole group roar with laughter at the incongruous sight of a white westerner previously known as a professor and surgeon showing there are a few things that he can attempt to do gracefully and fail utterly despite a sincere effort!
So, besides the wonderful way to spend a birthday week, and the rewards, both personal and for each patient that resulted, the numbers added up to 41 major operations, 18 minor operations, and 652 teeth extracted!