Daet, Philippines, Feb 9-22, 2012

3/8/12

Posted by Ethan Handler, MD (a fourth year Head and Neck Surgery resident from Kaiser Permanente Oakland in while serving a global health elective in Daet, Philippines with Bay Area Surgical Mission).

We left for Manila around 11 pm on Feb 9^th from SFO.   Seventy large boxes overflowing with medical supplies accompanied us in the belly of the plane.  This was the first of two flights, capped off with a four-hour bus drive over rugged terrain, through sparsely inhabited villages, stopping at the buried church for a quick photo op, to finally arrive at our destination, Daet, located within the Camirines Norte province.  An active town of over 100,000 people, bubbling with life, overcrowded with hundreds of motorcycles jimmy rigged to decadent and colorful sidecars. 

Our accommodations were very comfortable, located a few blocks from the windblown beach famous for kite surfing, and a few kilometers from the hospital.  We arrived on a Saturday afternoon, Friday, a day that only existed in our minds.

Sunday morning we were awake and working, furiously unpacking supplies, setting up the two connecting operating rooms that would house a total of 4 OR tables.   The local government was very generous to grant us use of their hospital for our mission.  Unpacking was followed by a trip downstairs to evaluate the packed clinic for surgical candidates.  Native Filipinos traveled from a variety of provinces, alerted to the medical mission by radio and television broadcasts.  Three services were represented during this trip, Oto-HNS, General Surgery, and OB/GYN.

The majority of our head and neck cases were subtotal and hemi-thryoidectomies.   There is no iodinated water supply in these far reaching areas and as a result there is a higher incidence of thyroid goiters and disease.   In addition, a few thyrogloassal duct excisions were also performed.   No mass was under 5 cm. 

Right outside the OR doors was the designated “procedure room”, although in reality it was a hallway.  The lighting for these cases was via heat lamps that doubled as warmers for the newborn infants.  This was epidermal inclusion cyst heaven.  Every conceivable place for EIC’s to grow, we found, and removed.  The largest was a 10 cm mass on the posterior scalp, successfully excised without bursting. 

Every patient was beyond thankful, gracious, and possessed incredible toughness.   Even when offered, they would seldom take pain medication.  The recovery area and patient rooms consisted of 85 degree, 100% humidity rooms with patients and their families crammed onto cots.  Yet nobody complained.  Their stoicism and strong will was an example for all of us, and a point to remember.

We operated full days, all week long.  Our nights were packed with various hosted events sponsored by local organizations.  Everyone was gracious.  I feel blessed to have spent time with these people, inspired by their courage and resiliency, while forging lasting bonds with the group members.  I’m always amazed and thankful as to how close you become with others when sharing in an experience such as this one.  Without a doubt, I would go back in a heartbeat.

A few pictures are included below:

Members of the surgical team.

                

         

Final Thoughts

2/25/12

Posted by Lisa Ryujin, MD (a fourth year Ob/Gyn resident from Kaiser Permanente Oakland reflecting on on her global health elective in Daet, Philippines with Bay Area Surgical Mission).
I came to the Philippines unsure about how I would feel about a trip concentrating on providing surgery. However, over the course of my time here, I have realized that providing these services to those who did not have the means sometimes meant changing lives. One of the residents and I would stay up late and discuss the ethics of the surgeries, making sure that we were supervised and performing the same roles that we had in the USA. We talked about the responsibility that we felt for our post operative outcomes and how important morning and evening rounds were in making sure our patients were well taken care of. My attending and I were talking about the ‘magical post operative day 2′ and how happy and pain free the patients were. They asked to take pictures with us and took the post operative medications with huge smiles. We also talked about how wonderful it was to work with the Filipino nurses an the familiarity of our own nurses. They worked together as a team, and at the end of the day, the patients always came first.

I’m so grateful that I was able to participate in such a wonderful group effort, it was a true pleasure, and I can’t wait to come back!

Me in the OR

Hardest days

2/17/12

Posted by Lisa Ryujin, MD (a fourth year Ob/Gyn resident from Kaiser Permanente Oakland currently on a global health elective in Daet, Philippines with Bay Area Surgical Mission).

Yesterday was the hardest day of our mission. Our first case was a suspected endometrial cancer, and when we finished the surgery, we cut open the uterus and confirmed, but there was not time to stop, we had other cases waiting. The next case was a 26 week sized uterus who wanted a myomectomy to preserve her fertility, another hard case. Then, simple appearing ovarian cyst removal that ended up being ovarian cancer. We had to pause and think of our mission, do no harm, we had not consented her for a hysterectomy, and her spinal anesthesia was quickly running out. One of the local nurses ran out of the operating room to find the patient’s mother to ask for permission to take the uterus and the ovaries with the hope of low stage an cure. We waited as the patient got more uncomfortable. By the time the nurse came back to give us the permission, we had almost run out of anesthesia making the surgery impossible. The anesthesia crew was wonderful and put her under general anesthesia and we completed the case. The last case was difficult - 18 cm bilateral ovarian cysts. After a long day, we had to go round and I had to sit down with two patients and their families and tell them that they had cancer, with a translator, in a foreign context. It was one of the hardest days of residency and it and it made me respect and wish for our oncologists.

After the discussions with the families I rounded on the rest of the patients and took a shuttle home. It was a hard day and I fell asleep immediately.

This morning when I woke up and went to round before our surgical cases, I was amazed how wonderful they were doing. Even though it’s been exhausting, it’s been one of the best times I’ve had in medicine.

 

The team

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

We brought everything we could possibly need on this mission: drugs, equipment, and even an ultrasound, we ran out of shoe covers first...

Arrival

2/14/12

Posted by Lisa Ryujin, MD (a fourth year Ob/Gyn resident from Kaiser Permanente Oakland in preparation for a global health elective in Daet, Philippines with Bay Area Surgical Mission).

It was a long 14 hours from San Francisco to Manila, and then one and a half hours to Legaspi and then 4 hours by bus to Daet. It took two full days to set up the operating room and today we had our first day in the operating room. There are two operating tables per operating room, only one anesthesia machine. We have been operating side by side and since we operate in the pelvis, we have been doing our hysterectomies under spinal anesthesia. It isn’t that hard to get used to, we operate on cesarean sections while they are still awake, but it’s just another layer that makes operating here a little foreign. But it’s been incredible what we are able to offer and how wonderful the staff has been. All our efforts revolve solely around patient care, what an amazing experience to share with the fantastic Kaiser team!

Members of our sugical team

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pre-trip thoughts

Posted by Lisa Ryujin, MD (a fourth year Ob/Gyn resident from Kaiser Permanente Oakland in preparation for a global health elective in Daet, Philippines with Bay Area Surgical Mission).

There are so many reasons that residents are interested in participating in global health projects. I have wanted to be a part of the development of clinics, medical education and self sustainability of medical facilities that are coming into their own. I have also been interested in the way medicine is practiced around the world, the different expectations that patients have of their physicians, and how we can better deliver quality health care. I have always learned much more than I have taught, and it has given me insight to different parts of the world. Up until this trip to the Philippines, I have focused on facility and medical personnel development, and much less with patient care.

In the past I have been hesitant to go on a surgical ‘mission.’ I thought that most places, even rural places, have physicians that provide wonderful medical care, and by going in and doing surgeries in places where there were local surgeons, we would undermine their skills. I also believe, that as a surgeon, you are responsible for surgical complications, and with short surgical missions, we are unable to deal with the possible complications of our surgeries. During past (Vietnam and Kenya) medical trips, I have never declined to participate in a surgery when the local surgeons have requested assistance, but when I did participate, it was clear how key communication during surgery is. In Vietnam, the names of the surgical instruments were in French, so even when I asked for standard instruments, the scrub would look at me bewildered. We take so many things for granted in our operating rooms, our wonderful anesthesiologists and CRNAs, our circulators and nurses and EVS make our jobs run smoothly.

At the last Global Health Educational Consortium, in Montreal, there was a session on the ethics of surgical care abroad. I attended, as I was interested to see the latest updates, papers and innovations. The West African College of Surgeons made a plea for more surgical missions. They said that in the major cities, there was a large concentration of surgeons, but in the rural areas, there may be facilities, but no doctors to staff the operating rooms. A Rwandan surgeon stood up and reported that after the 1995 genocide in Rwanda, there were a total of 5 surgeons and 2 anesthesiologists left in the country, today, there are still only 30 surgeons and 12 anesthesiologist to serve a population of 11 million.

Organizations like BASM (Bay Area Surgical Mission) are able to provide free surgical procedures in a place where all surgeries are a fee for service. And organizations like Doctors without Borders and Relief International, are able to offer surgical services to places in crisis. This is a wonderful temporary solution while simultaneously working on medical education, community development and self sustainability.

I am grateful to be able to go on my first trip, solely dedicated to providing surgical care, with people from BASM. A team that I have worked with every day at Kaiser Permanente in Oakland, a team that I love and trust, it will be a fantastic (and exhausting) opportunity to focus on patient care together. I am so happy to have talked with these surgeons from Rwanda, who had expanded my understanding of needs in other countries.

We fly out tomorrow for a 3 day journey to our final destination in Daet, Philippines. More to come!

Philippines Mission Reflections

2/2/12

Posted by Jennifer Do, MD (a fourth year Head and Neck Surgery resident from Kaiser Permanente, Oakland serving a global health elective in the Philippines with Bay Area Surgical Mission.

In January 2012, I was fortunate to participate in the Bay Area Surgical Mission(BASM) trip to the Philippines. I traveled with a 19 person team comprised of physicians, nurses, and technicians from Kaiser Permanente Medical Center in Oakland and Santa Clara, California.  The mission was lead by Joshua A. Gottschall, MD, a former Pediatric Otolaryngologist with The Permanente Medical Group who is now based in Orlando, Florida with the Children’s Ear Nose and Throat Associates.  Members of the Kaiser Oakland Head and Neck Surgery Department included Barry M. Rasgon, MD, Stephen V. Tornabene, MD, and me.  Luke J. Schloegel MD, a former resident of the program and soon to be faculty member, also participated.  There were two general surgeons in our group.  We also joined forces with a team of Ophthalmologists from the capital city of Manila as well as volunteer nurses and interpreters from the area. 

The mission drew individuals from a wide geographic area, with many traveling great distances through treacherous country roads and often stormy weather to be evaluated for the first time.  We operated in two small community hospitals in the neighboring rural communities of Tigaon and Sagnay of the Camarines Sur province of the Philippines.  Despite the challenges of limited resources and time, I learned that we could still deliver quality care.  Flexibility, dedication, and teamwork proved more essential than the “modern” conveniences of adjustable operating tables and high-powered lighting.  Over the course 6 days, were saw many patients.  Of these, 40 received major operations and 97 minor operations.  Otolaryngologic cases included thyroid lobectomy and primary cleft lip and palate repair.  The ophthalmology group performed 146 cases of cataract and pterygium surgery.

Our mission trip accomplished the goal of treating an underserved population with otherwise limited access to medical care.  Both personally and professionally, this was a kind of priceless experience that will enrich the practice of any physician.  I would like to thank the Kaiser Permanente Global Health Program for their generous support of this truly inspirational trip.

(Part of the surgical team: from left to right they are the following: me, Joshua Gottshcall, MD, Barry Rasgon, MD, Luke Schloegel, MD, and Stephen Tornabene, MD)

(from left to right, me, surgical tech Rebecca Benevides-Fulk, and Luke Schloegel, MD)