Thursday, a better day

The lady is anesthetized, lying on her stomach. You can see her  head at the top of the picture.

I was tired and stiff in the knees when I got up but I spent a pleasant half hour sitting on the patio, enjoying the breeze and checking my email. We had a complimentary buffet courtesy of the hotel. The sticky rice with mango was good. At work it took a bit longer than usual to get under way. Our first case was the lady with the neck mass. It was necrotic and smelled bad. She wasn't bad to intubate and the cautery was working! We lost about 120 ml of blood during the dissection, not bad at all.

The mass came off easily with no extension below the fascia.

My second case was a 71 year old lady with calcified masses on both hips. They were almost symmetrical, the left being larger. Turns out they were probably TB of the ischium. That's two cases of pelvic tuberculosis in two days. Must be common here.

Dr. Lotuaco swung a flap from the inter-scapular area to allow a skin closure without tension.

Case #3 was a five year- old girl with bilateral popliteal cysts. I worked with Dr. Enescio, a general surgeon and Rotarian from here. We did this case with the patient prone, but by then turning and positioning people was old hat.
Case #4 was a hernia repair under spinal. The man had what looked like a foot of small bowel in the hernia sack, so he will feel better from this. My spinal didn't work so I put him to sleep. This vaporizer can be very frustrating at times, when you want to put out a lot of anesthetic and it won't cooperate!

Not a varsity anesthesia machine. Leak of 4 l/min @ 30 cm H20 pressure.  Vaporizer output non-linear,  seemed low overall. But then, it is an isoflurane vaporizer filled with halothane. 

I was on the last van out and returned to find a Rotary send off underway. Ideally they would make their speeches and present each other with trinkets and certificates first, waiting for everyone to arrive before they eat. This is not the Rotary way. Fortunately their was plenty of food left and the barbecued chicken tasted great.

Speaking of food: Thursday one of the nurses gave me some dried, fried squid that was very chewy but had an interesting, garlicky flavor. At lunch I had some skate wing that was marinated and tasted okay

Wednesday in Labo

Wednesday in Labo


The rain stopped yesterday afternoon and this morning it seemed like everyone was in brighter spirits. We had a group photo before boarding for the hospital. I looked in on the three pediatric cases from yesterday. Everyone looked good, including the one month-old who had the apnea problem in PACU.

She has a good surgical result, but if we hadn't had good care in PACU it might have been a disaster.

The first patient for OR today was a fifty-ish lady with a lipoma the size and shape of an eggplant arising between her scapula and distal clavicle. I say fifty-ish because she is an Ito, or Negrito, one of the indigenous people of the Philippines. She spoke no English and I'm not sure how much the Filipino nurses could talk to her, either.

Ito lady positioned for removal of lipoma. Note patio chair supporting arm board.

We couldn't get the cautery to work, so I asked to put the second case, a lady with a tumor on her occiput and upper c-spine, on hold.












I had case #4, a  gent with a tumor of some kind between the first and second metacarpals of his left hand come to pre-op. Leila, one of the nurses who works part-time in a pain clinic, helped me put in an axillary block. I had no nerve stimulator but I got a paresthesia and used 50 ml of 0.25% bupivacaine. Still no cautery, so we went on to case three, a 21 year-old lady with a thyroglossal duct cyst. That case went well.

At lunch the  surgeon told me he thought he could do the neck mass without cautery. In my view, her hemoglobin is 10g/do, we have no blood bank and she isn't going to bleed less than usual just because she's in the Philippines. So I held firm on the cautery. We had a break while they rigged up a tourniquet for the hand case. We had no way to measure the pressure but by keeping it pumped up as high as it would go we got a bloodless field and completed the surgery in 64 minutes.

Well and good, but after the dressing was on and the tourniquet released he started bleeding through the dressing. Holding pressure didn't help so we had to open the wound and ligate a couple of bleeders.

It turned out that when one of the nurses told the lady with the neck mass she wouldn't have her surgery she started crying. The new plan is to operate on her on Thursday, planning to back out if bleeding becomes problem. There are a couple of logical faults here, but I hate to have people crying. So she is first case Thursday morning, because if you are going to do something that may lead to problems, it's best to do it early in the day.

I was going to do a hernia repair but we were put on hold for a possible C-section. A lady came in laboring. She delivered a 1.5 kg vertex girl, but there was an undiagnosed second breech baby. I set up to do a general and brought our last spinal tray into the room. When the lady came in to operating room no one could tell me how much blood she'd lost or how urgent was the section. Her color was good, her systolic blood pressure was over 130, so I went ahead with a spinal. The baby was pretty floppy and they had no means of suctioning her. I'll check on her tomorrow. The change in schedule led to a conference, the upshot of which was that I would stay to do two more cases with the local surgeon. I had to wait for a while but we got #5, an inguinal hernia and #6, incision and drainage of a sacral mass that was cystic that will most likely turn out to be TB, done by nine pm.

Abscess with caseating material arising from the sacrum.

I got back to the hotel about ten, had supper and went to bed.

Tuesday in Labo

Our first infant (4 month) cleft lip of the mission.

If baby #2 (four weeks)  had severe feeding difficulty it would have been  more urgent to address her cleft lip.

#2 looks good the afternoon of surgery, after all the excitement in PACU.

I slept better last night. I didn't hear my roommate, Ron, get out of bed but I woke up when he opened the bathroom door. I was on the first van to the hospital so I had plenty of time to set up. First case was a four month, four kg child for a cleft palate repair. Apart from difficulty placing an IV the case went well. I gave the child infra-orbital nerve blocks, going in through the buccal mucosa, and the baby was very comfortable in PACU. The second case demonstrated why its not a good idea to operate on children less than fifty weeks post-conception. Bilateral lip, four kg., same technique but this child (27 days old) had about ten minutes of apneic episodes after fifteen minutes in PACU. I bagged her a couple of times and gave her jaw-thrust airway support. The third case was a two year- old for a lip.   #4 a fibroma on the left side of a two year-old's nose. #5 a two year-old with a cyst in front of her left ear. The infra-orbital blocks worked well. Tess Sabado , the anesthesiologist who is president of the local rotary, was interested in the caudal that I gave #6, a ten year-old with a right inguinal hernia. #7 was a very slender 33 year-old with a right hydrocele. He got a spinal. Some very nice spinal trays turned up and I was happy to have them. Tomorrow promises to be busy, but no pediatric cases.

This young lady was not too excited about meeting me, even after I gave her  five pesos.

Our first day at Labo District Hospital

The Rotary did things right with a sound system and tents in the front yard for people waiting to be seen in clinic.

First day in Labo.   I woke up at 12:30, 3:30 and for keeps at 5:00. It rained all night and was very humid in the morning. We made good time getting to the hospital about 7:30. Unpacking was slow mainly because we brought a lot of things we won't use and some of the drugs that we will need were wantonly tossed into a box filled with  shipping peanuts. Finally everything found a home and we did our first cases starting about 1:30 pm. I put a 13 year- old boy to sleep for a cleft lip repair. His age was not certain because his mother abandoned him. The guy was very brave about the IV. It's a little eerie to put someone to sleep using just a blood pressure cuff and a pulse odometer for monitors. I've had to cross-fill an isoflurane vaporizer with halothane and I'm not confident in the vaporizer output. It seems to shut off if I set it for less than 2%. Anesthetizing  infants tomorrow will be interesting.

View from the operating room. The bull seemed pretty tame, no tether.

Our second case was a ten year-old for a keloid excision from the right pinna. The mass looked very ugly so I hope he gets good result. I used a LMA for this case and all went smoothly. I have five cases for tomorrow so I hope the day starts on time. I have to be mindful about cutting corners: the rule of tens, for instance. One of the local docs had a two week old for a cleft lip repair. I stood by the 10 weeks, 10 pounds, 10 grams of hemoglobin. I hope the baby gets fixed before too long but it' s not right to take chances on these kids.