JAN-B-8
THE FINAL OPERATING DAY AT TECH AMONG THE TBOLI
WITH A REDUCED STAFF AND EQUIPMENT, YET LARGER CASES,
AND, AS ALWAYS, THE ADD-ONS AT THE LAST MINUTE
BEFORE COMPLETING OUR SURGICAL MISSION AT EDWARDS, TECH,
AMONG THE GRATEFUL TBOLI PEOPLE
January 17, 2003
We have done it! We have just completed 76 operations, 58 majors under general anesthesia, with the 18 minors being anything but small operations (some of the lipomas I removed under a minimum amount of local anesthesia were more than a kilogram!) ---all in 4 ½ days of intensive high volume operating----and this without significant complications!
But, you say, we are only doing minor lumps and bumps, right? How about a radical nephrectomy for hypernephroma? How about two radical mastectomies on patients with Stage Three Breast cancers—one of them male. And how about “Goiter Plunge’,” two more of them today---and these are just a few cases among the sixteen cases done today!
THE LAST OF THE OPERATING AT TECH
IN A MARATHON OF SURGICAL PRODUCTION
This was our “light” day, since part of our team and equipment had gone back starting at 4:40 AM to return to Malaybalay and the BBH by what turned out to be a horrific, yet “ordinary” road trip in rural Mindanao by way of Davao City. Don, our most expert anesthesiologist, and Wilma (or “Wing”) our diminutive OR circulator who has just made her first trip to Tboli land to help with the surgical volume from her expertise as BBH’s surgical nurse, and some of our medical instruments had left. I had seen a few patients to be done today, including three more goiters, two hernias and a hydrocele, and the special case of the woman who had a kidney mass felt on abdominal exam after hematuria, then had an ultrasound and IVP showing a normal right kidney with a displaced left kidney.
We each started out doing what could be done as a “warm-up” in our sleep—I did a goiter in a young woman—only 17. But already she comes in with a very large and meaty thyroid filling all her neck. Alan did another case and then we joined forces in doing the radical nephrectomy. The biggest challenge in this case was getting the patient positioned up in left lateral lithotomy position, using tape and gauze to suspend her left arm on a re-rod ether screen. We started her as a big case, and, as many do when this approach is used, the case became simpler and much more easily controlled. If a small case is going to be done in a hurry, it usually expands to become a much bigger case in front of the stumbling and staggering eyes of the overwhelmed staff. We made the flank incision and I pulled down the Gerota’s fascia and got control of the renal pedicle, on which we placed the pedicle clamp. All told, it took less time with less blood loss than the average big goiter thyroidectomy.
Without disturbance of her peritoneum or pleura, she was eating the same day and could be getting ready to go home by now. This is the kind of case for which a big blood bank would be necessary, and a standby thoracic surgical team in the event that it was necessary to do a thoracoabdominal incision, and it was all over in less than an hour.
I still had a couple more goiters to do and a pastor with the large fungating breast cancer, recurrent over his left chest wall. We had lunch, and came back to do several other cases, like lipomas under local—one identical to the one I had done the day before bulging out of the axilla. Along the way, I saw a woman with a right breast rock hard five centimeter mass—as surely breast cancer as if it were a glowing neon sign. We had to do her and soon, since she would have essentially only surgical therapy at her age 34. Ideally, it should be followed by Tamoxifen therapy and chemotherapy, but neither is likely to be available for her. To give her maximum benefit, she might have oophorectomy (ovaries removed), but that is the best way to treat recurrent breast cancer. Since that is the only “arrow in the quiver” after mastectomy, we should wait until next year when we see here her again and if she had recurrent disease then, employ the Oophorectomy, before presuming that a “prophylactic “ oophorectomy done now would benefit her. So, we booked her, right behind the pasotor who is going to be first before her in getting a later stage breast neoplasm removed.
We stared out with a wide elliptical incision around the breast mass, and undermined far and wide in order that we could pull the edges of the skin closer together. When we scheduled him, I had been told that we had a Humbie knife to take the donor skin from his thigh to cover the big defect we expected. Only later did I hear that the Humbie knife did not have a blade, so it was useless.
We started with a wide elliptical incision around the big fungating mass, and I went down through the fascia of the pectoralis major muscle. The specimen was excised, and then I undermined the edges as far as I could. Then, using the “far/near/near/far” suturing technique (akin to the “block and tackle” method) of hauling things in under tension, I pulled the opposing skin edges toward the midline of the widely gaping defect to cover it. To my considerable surprise, I was able to worry the skin edges together primarily, so no skin graft will be needed. We sent him to our recovery room, where overly attentive family members hovered over him, making him about the only invalided patient we had there, with all the others “taking up their beds and walking” as soon as they were nearly emerged from anesthesia.
With that done, I was ready to call it a full week’s work, when I saw the other goiter woman in the waiting queue, all prepped and with an IV running to come in. So, we began this “routine, but large,” goiter. It, of course, turned out to be one of the “goiter plunge’” variety with a lot of the gland in the mediastinum from which I had to fetch it up and deliver it. She even had a parasitic nodule not associated with the right or left lobes which I fished out of the area behind her trachea and esophagus—a fitting conclusion to our “Goiterama!”
I might have reported several of the details of today’s’ efforts in greater detail and word pictures, but I also shot enough film that I may substitute one for the other and try to get to bed, sop that my retiring earlier and getting up before dawn to get into the competitive position of near the front of the shower line (having that whole team focused around one small bathroom is a job requiring planning and four AM showers if they are to be had at all!)
Don and Vivien came over as well as a number of other well-wishers and we will talk with them before turning in, and closing the chapter on Tboli land for 2003, with many requests, no, pleas, to return next year with an even bigger team to do still bigger and more cases. The word had been spread up in the mountain districts, and about 70 additional goiter patients had been mobilized to come down to the roads to be picked up by the village mayors who were given instructions and support for carrying them from the mountain remoteness of their villages to the TECH center here—but failed to do so. So, I still have an equal number of the goiters out there in the mountain remote fastnesses equal to those done this year, to be done next year from this year’s promised operations, and that does not count on any more joiners coming in for the subsequent years’ discovery!
Any joiners care to participate in Goiterama—04? We may pause in thryoidectomies every once in a while to do a few additional small cases that pop in from time to time---like radical mastectomies, nephrectomies, etc!