JAN-C-5
A FULL OPERATING DAY, ENDS WITH A SOLO THYROIDECTOMY
FOR THE LARGEST GOITER YET,
AND A DISCUSSION BOTH MEDICAL AND TECHNOLOGIC
WITH PLASTIC SURGEON MORELLA WHO SHOWS ME HER
SINGLE UNIT CELL PHONE, PDA, WEB ACCESS, EMAIL, CAMERA, WORD PROCESSOR
January 21, 2003
I have just come back to the Guest House well after dark, after a full day operating, but in a crescendo of cases that may have started slowly, but ended with me alone doing the biggest goiter seen so far, with a patient who did very well after this swift and complete operation. Along the way, I learned a few things from Dr. Morella Mijares, the plastic surgeon from Sebu City who had volunteered to come down on the overnight boat from Sebu City, the same we will be taking on Friday night to go up to her town in transit across to Leyte. I learned things both medical and technologic from her, despite her asking me for my consultation and advice, which is flattering given here demonstrable expertise.
BETH: 08* 04. 34 N
125* 97. 24 E
I know I have not recorded by GPS marks for a while, largely because the places I have been I had been before and already have them marked inside the GPS as landmarks... But, this landmark of latitude and longitude reminds you that I am only 8* above the Equator (compared with the lower and even more equatorial latitude of Tboli-land at BING = 06* 14.35 N, and 124* 46.36 E) so that you can see we are in the torrid tropics, but still in the northern hemisphere, so it is “winter” here. This means that it is not as hot as it would be the rest of the year, and that it might rain more, which it did all yesterday morning. This warm moist climate give rise to the tropical biodiversity and the huge number of fruits and rich explosion of flora in the Philippines in their Pacific Island location just above the equator. It is also on the far side of the world (GMT is closer to us here than is the time zones left behind in the US). You can see we went beyond the 180* meridian when we crossed the dateline and we had “gained on” the longitudes so that we are closer to the Greenwich prime meridian going further west at 124*, so we are measuring our position as East, rather than West from Greenwich .)
I wandered around the wards and pulled drains and saw the post-op patients. By that time the first patients, largely palates and clips were being done and it took forever to have these patients emerge from the anesthesia. With our inexperienced and insecure staff of anesthetists in the absence of the superbly efficient and gifted anesthesiologist Don for the day (as he was doing an orthopedic case at the Provincial Hospital—the first anesthesiologist that BBH has had arriving only in 1997 in the 44rh year of the hospital’s running as a surgical establishment) Charles always took twice as long to awaken the patient as my operations took, tying up valuable “OR Real Estate” non-productively. So, the morning’s OR schedule for me only consisted of a patient who had a recurrent inguinal hernia that I would show Jovi how to do under the mixture of local anesthetics—Marcaine and Lidocaine with Epinephrine, for short acting local anesthetic and long-acting analgesia.
Our guest plastic surgeon who arrived yesterday by the overnight boat from Sebu City is Morella Mijares. She is very gifted and had done a remarkable job of reconstruction on the Tboli patients we had brought up last year including the woman, who had a stricture of her mouth, named Lilia, and the Captain, who had been shot in the face at the election time for voting the wrong ticket, and, of course, Josephine Tano. She and I discussed the patients she would be doing today, since she said she genuinely wanted my input, as a consultant who could not do what it is that she can do, but an independent judgment, since she would say she rally did not know from one operation to the next how the next stage could go. After we had talked about cases, she showed me her new toy, a gift from her brother.
Her brother is Dionisio Mijares, who is the captain of a container freighter ship that regularly makes a run from Subic Bay in the Philippines (site of the former big US Navy Base here) to Japan. The Subic Bay port is now the headquarters of a number of computer industries, including Dell, and Cisco. He carries containers of these products out, and on return, drops off used cars which go up to Manila to be disassembled for their more valuable parts. He is savvy about many electronic things and got for her a cell phone—a Nokia 9210---there is already a more advanced issue called Nokia 9210f. This looks likes an oversized cell phone, with the usual keys on one side, through which every Philippine seems to be sending or receiving text messages for a peso per message anywhere in the islands. (Big road signs announce “Do not Text while driving.”) But the phone folds open, and inside is a screen and a keyboard, and it is a full computer. With this device, she can type messages in a word processor, make slides in Power Point, use a spread sheet for accounts, consult her appointments, etc. But, get this, she can also email directly from this phone, anywhere on earth, using the satellite for the phone. She also has a web site here and the phone can surf the web.
But, now it gets even more interesting. She has a small digital camera called “Concord” for Nokia, and she can take pictures in the OR or anywhere, including family pictures etc. She can then simply download the pictures via an infrared port on the camera and the cell phone and send the images anywhere she wishes to. So, we reviewed several of her recent patients and sent them as messages around the world, along with requests for consultation. She has different rings associated with different callers, so that she knows without looking who is calling, and whether to take their call. She took a picture of the pre-op patient and infra-red transferred it to the phone and along with a text message, sent it back to Manila, for a total cost of a peso (2 cents.)
My GPS depends upon satellites overhead which I often think should be used as transponders, not just sending signals but relaying them so that the hand held unit might send a signal to the satellite. That is also in her phone, in which there is a GPRS –like my GPS but with a responder. So, as in the smaller AUV’s, the Asian tiers are making electronic miniaturization of utilities and putting them to use before we have them. She can download her cell phone to a desktop or to a laptop, but she has not had to hook it to any other computer, since it can do all these things without going to another “smart terminal.” Neat tricks are coming, and although I am shooting film, I know I will eventually have to go digital for images, but do not want to get in on the prototypes being made now until the “packages” of these chips makes it more integrated. Piece de resistance, she also has the “MP-3 equivalent” for music and the capacity to put audiobooks on tape on such a device, so she would have in one “cell phone” all the parts that I want to avoid carrying in multiple machines. There are, of course, abundant accessories for such a device, like hands free sets, and expanding keyboards etc. Ah, technology! You have to get into it somewhere—and her I am at least as far as laptop and SLR film photography!
GOITERS ARE US
The next patient I was to teach Ragon how to do a big goiter under local anesthesia. Without Don here, and with the anesthetists tied up in cleft lips—or, more accurately, arousing post-op cleft lips to get them to emerge from general anesthesia—we would do this goiter under local anesthesia. So, we did a cervical block, and infiltrated the skin, and set about doing the goiter.
The patient was moaning and moving. At the point when I had to tug and move the goiter off the trachea, she was very uncomfortable. Coughing and struggling, as would anyone who felt their airway was being throttled, and I suggested to Ragon that we swiftly excise the goiter off the front of the trachea. He placed a clamp at the base of the goiter and uncharacteristically pushed hard at the same time as the patient bucked and he cracked an anterior tracheal cartilaginous ring. Immediately I could hear the hiss of a tracheotomy, with a few blood bubbles emerging. So, with the goiter still in our way, we went about repairing the face of the trachea with a purse string suture so that she would not have the tracheostomy which this procedure might lead to, and we then removed the goiter. She was also given some IV Ketamine, and with that she slept soundly as we finished the thyroidectomy.
We repaired the trachea with absorbable suture and then returned her to the recovery room where she slept off her injected analgesia, emerging fine. That may have been enough excitement for a time, but there was another goiter awaiting, and this one was the biggest of the week. Ragon was gong to go next door and do a hemorrhoidectomy under spinal and Jovi was going to assist in an undescended testis repair. I said I would get the thyroidectomy started, and then let them complete it.
It was over before either finished their smaller cases. The goiter was very large, but fortunately not very difficult, and I did the whole thing with only Wilma, the diminutive scrub nurse assisting. “Would you like to learn how to do a large goiter Wilma? “ I asked. It is faster, and easier for me to simply do these operations, but that does not indigenize any skills to be left behind. Dr. Mijares came in to watch the procedure, since she was awaiting a case of her own to be done. We talked as the one kilogram goiter came out—a large and meaty gland which is probably the biggest we would do here at the BBH—although I hear there are five more to be done tomorrow and on our final day.
So, we returned late to the wonderful meals that Willie and Betty prepare for us, and sat and talked as the last case of Dr. Mijares was being completed. One of the things that was asked of me is to explain the geopolitics of oil in the Middle East and the difference between Shia and Sunni Islam and what difference that makes in the areas of Iraq, Saudi Arabia and Kuwait. All of this seems to be a topic of hot and recent conversation, since the UN inspectors have “discovered” what US intelligence has known all along, and they found the missiles and the weapons of mass destruction without their loaded warheads. Apparently, the Iraqis are saying that despite their denials, these were always known to be there, and Bush is eager to use the forces they have there to take them out, while Hans Blix is saying his team will need a few more months, etc. I only hear this current news from Fred who has gone over to surf the news channels on the internet, since he has fewer cases to be doing now.
In comparison with Tboli, where we invent the OR under our occupation there, BBH already has a hospital and a facility for the ongoing use of these OR’s and a very capable staff who runs them. So, the need for our services is less, and because of that superfluity, Jennifer is bored, since there is less to be done.
But we still have time taken for long and delicious meals at lunch dinner and breakfast, each of which are multiple course prepared by Willie and Betty, so we will not go hungry. And, they keep finding things for me to do in cases to be operated. I just know that there will be a great rush on the last day to add in many additional cases, even while we are trying to make a light day on Wednesday, so that the staff can get to their rehearsals for the program they are planning for us on Wednesday night. You will be there with film and tape!