Day 3 Iligan Mission

img_2182Day 3 and 31 cases in!

We have had plenty of large difficult procedures, all life changing for both the patients, as well as the team. The stories from the families include: a young girl with an encephalocele (this is a birth defect where a person is born with a hole in her skull that allows part of the brain to protrude). She was unable to be cared for by her biological mother, abandoned and was then rescued and raised by her cousin.

Not all of our patients have such dramatic and tragic stories. Most of our folks have quite simply had to make life choices that impeded their ability to attain surgical care. This means we have patients who have been suffering from various problems for 12-25 years! YEARS! No tragedy, just simple life decisions made on life choices. This is the primary need we are filling. We are caring for people who have had to defer their health care due to life chances and choices. We aim to help them get back on their feet and to they walk of life. So far so good. We pray that we continue to do the work we are called to do, with the quality we aim to provide, and with the compassion and love we are commanded to share.

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Mission Iligan Philippines

Working in missions is humbling in so many ways. Just today, we noted on the aspects of daily life that we absolutely take for granted moment to moment. The predictability of presence of things like water, a trash can, an easy restroom to use, and even warm bath water. These things are not absolute givens.

We all take for granted the very things other people consider pure luxury. In life, this may show itself as uncertainty of the time of a meal, the time of a ride home, or maybe even whether or not we will have a meal. When doing surgery in a context different from our daily lives, the little things are all opportunities for stress. They are all variables. Even the person who is responsible for handing you instruments is new and unfamiliar.

All things on mission trips are uncertainties, new experiences, unknowns even. Imagine dancing with a stranger. The first steps or even the first whole dance is a challenge, awkward even, as you struggle to anticipate, or maybe even match your partner’s movements. This is the same in many ways. The anticipation of another’s movements, of their needs, and their thoughts on where we are heading are all real.

In talking with one of our residents today, I asked her what she learned. She learned today that she is not as flexible, or versatile as she thought. She realized that she was much more fixed, and more needy around certain aspects of her work, than anticipated. Such an incredible lesson to learn in the field. There is a reason that fast food chains work. We are all creatures of comfortable habit. Meaning, habits or patterns of behavior, create a façade of familiarity. They create an environment or context with which we are familiar. All of this lowers the levels of stress and anxiety.

The term “preference card” is a misnomer.(A preference card is a wish list of items and supplies that a surgeon puts together for surgical teams to prepare for each surgery.) Many of us might rather call them “absolute or all or nothing cards” because we hold them so close to our minds and hearts. How we work is typically how we were taught, or evolved over time to work. Neither of these things are easily changed. They are kept as a pattern for a reason. We find what works best for us and our patients alike.

This undergirth of stress and unfamiliarity and dare I say instability, is something not altogether different from what people in poverty experience every single day. It has been termed “toxic stress. The uncertainty around finances, food, shelter, safety from violence and maybe even the possibility of employment, all contribute to create a context of multiple stressors for an individual or family. This toxic stress is so powerful that it has been shown to lead to negative health outcomes around infection, hypertension, atherosclerosis and central obesity. Toxic stress in a mother even affects a growing fetus as it is developing in utero.

We reflect on the stress that we experienced today, with a little different set of instruments, with new staff, with unfamiliar operating rooms, beds and equipment, and with patients that look different than our usual Memphians/ Chicagoans/Seattle-ites/Sacramentoans. Now think how this little bit of stress affected how we felt at work today. This work stress is a mere fraction of what our brothers and sisters in poverty experience every single day. These are things we will never understand even just at surface level unless we seek to find out. Maybe this is our lesson of the day: Seek the lessons that teach us to be more sensitive, and increase our ability to recognize, or maybe even anticipate, the stressors the people around us might be experiencing.

Tagum Mission Journal

Day One

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This morning, after arriving in Davao, we were quickly whisked off to join the Bishop in Tagum who will be hosting the majority of us at his house. We had a lovely breakfast with the priests and I had a chance to have some conversation about the work they were engaged in in Tagum. One particular priest, Father Tom, has been here for over 11 years. He grew up in Tagum, and since the founding of the community by an American Bishop, Bishop Regan, he has known that he wanted to be a priest.

After covering some of this background, Father told me that Tagum is a city of around 210,000, but the diocese covers about 1.5 million and totals 40 parishes. On their latest survey “the Church” was still the most trusted public entity for over 70% of the population locally. This foundation as well as the extremely organized infrastructure across their community is what allows them to be so efficient and effective at their outreach, Father Tom said.

For example, on December 4, 2012, Typhoon Pablo struck the community of Tagum and the surrounding small towns including Compostela, Nabunturan, and New Bataan. The majority of the people affected by the typhoon were banana plantation workers. These plantations were rented by Dole, and after the banana plants were destroyed, they too left with destruction and hardship in their wake.

Within hours of the storm, the community of priests in this same area began to respond with relief efforts by partnering with outside national and international agencies. This is initially how we came to be in touch with this community. The priests also began their own longer term planning for their parishioners. The community of priests I speak of includes clergy with backgrounds in engineering, architecture, business, etc all on the foundation of theology and service. Naturally, in extension of the support of their local communities they immediately planned for a response to the economic and structural hardships that were to come.

The architect priests drafted simple house designs while others taught the others how to make hollow blocks out of sand and still others, how to install electricity. In this way they were able to quickly devise, share and pass on plans to their communities much faster than any outside or governmental assistance. To date they have built 500 homes and provided skill-set training and thus jobs for their community in the past year.

It is this same community that we are serving during this mission.

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Patient screening today happened without troubles. Most of my patients today are banana farmers or work elsewhere on the plantations within other capacities. One of my ladies in particular shaved the bananas before they go to the dehydration plant to become dried banana chips.

They all traveled approximately 2-3 hours to see us for their final screening today. Majority of them have massive thyroid goiters and have been waiting, symptomatic, for at least 7 years. They have oftentimes been seen by a surgeon but have not been operated on due to lack of funds. (hmph, heard that one before…)

One patient of mine has actually had symptoms for 20 years! Another has had a massive growing posterior auricular hemangioma for 7 years. A 20 year old has had a papillary carcinoma of the thyroid for 2 years, all while awaiting for funding. One little boy of 6 years told me today he was getting beaten up at school and showed me a round scar on his forehead. His mom told me a boy hit him hard with the eraser end of a pencil that had long lost its eraser. He was teased and bullied because of his cleft lip. In the FIRST GRADE.

Another was a 20 year old young woman who finished high school but was afraid to go to college because of the speech barriers her cleft palate generated. Therefore she stayed at home near the plantations and helped her parents with their work. As we were discussing surgery, we chimed in that she would definitely need some speech therapy (or speech exercises as they call it here). I have never seen someone SO happy to hear the words “speech therapy!”

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Here is a selfie with just a part of the team that helped my dad and I see and schedule 47 patients today!

We look forward to the rest of the team arriving tomorrow, morning mass at 530 (we are staying at the Bishop’s house) and the last wave of patient screening in the morning. THEN….we get to set up the operating room! My favorite part! Aside from the actual operating 🙂

Reflecting on how all of this is happening (as it often does in this work) as a result of a community of faith responding to the specific health and social challenges of their community. This is much like our work at the Church Health Center. In fact, I talked with Father Tom about our work at CHC, and how in a way, what they do for their community is much like what we do for ours back home. He replied quite simply with “that is what it should be” and he is right.

Day 2

Today is the first day our entire team is complete! It is 7pm and all of us Westerners are crashing from the jet lag. In total our team of 28 folks represents the cities of Seattle, Fresno, Sacramento, Memphis, and Phoenix. We also welcome friends from other areas of the Philippines! Such a relief to have had the entire afternoon to set up our four OR tables for tomorrow.

This morning we conducted a free medical clinic for the poor in our immediate surrounding area of Tagum.

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On my interviews, I became aware of the fact that many of them were food cart owners, some of them banana plantation farmers and the like; still very much in our targeted clientele. It is evident that the local community health workers worked hard to ensure we would meet our target audience.

Most came to us with complaints of cough and fevers. Not surprising considering that they persistently breathe in the fumes of burning trash, burning diesel and on occasion burning nicotine. Some of our most pressing patients were malnourished families of a mother of three, and a large deforming probable squamous cell carcinoma on the forehead of a 20 year old girl.

We are conducting our surgical part of the mission at the Diocesan hospital called Bishop Regan Hospital. Here it is below!

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They have an amazing and skilled staff and much more infrastructure than we are used to! It was founded by an American Bishop years ago as a charity hospital. While our surgical team stays here at Bishop Regan, our clinic reaches out to the smaller communities directly, as the majority of our patients are plantation workers. The clinic is therefore a mobile entity.

Day 3

Our first day in the OR proved to be a smooth steady effort! Each team performed 6 procedures, and to date it was the first day that I did 4 thyroidectomies in a single day. Dr Deneve and I ended our day around 10:30pm I think. All of our patients were so gracious, and in the spirit of sharing their story, more than willing to be a part of our mission, our sharing of our mission and stories!

Below is Dr Jig Deneve (right side, surgical oncologist at UTHSC), Rob Conley CRNA (center, formerly at Methodist LeBonheur, now Kaiser Permanente) and Chad a local OR tech (left) as we start our third thyroidectomy of the day :

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Above is Monette RN from Seattle (left), Cora Padua CRNA (Center, Regional One , Memphis TN) and my dad! (right, CRNA) They are inducing anesthesia in preparation for surgery. Behind them is our army-grade anesthesia machines, trusted companions on many many trips for us.

This is Mr Sasi, a banana plantation worker.

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When I asked him if he would mind me sharing his story with the world, he heartily agreed and said thank you. If he had internet or a computer he would love to see. He has had a hernia in his left groin for over 12 years. He has been unable to get it fixed due to finances and inability to leave work. At his age, he worries about his job going to someone younger and more spry.

Our thyroidectomies here in the Philippines are much more advanced than those we see in the states. Below is one of our “smaller” specimens. Mind you, this is just one side. 🙂

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In total we performed 12 procedures today, ending our day with our last patient in recovery room around 10 pm. Exhausted yet pleased with the progress of the day, we are happy!!! Our patients are safe, happy, comfortable and Christmas-level-excited about receiving surgical care that they have been seeking and waiting for for years….

The majority of our patients are Christians, but we also have a significant number of Muslim patients. Regardless, they are interested and happy to pray prior to and in preparation for surgery. The spirit is viably important to the most of them, especially in light of the fact that they have a tremendous amount of trust and respect for the church here. Without that established relationship, our outreach in these communities would be near impossible.

Day 4

Today proved to be a fruitful one, full of very challenging but safe and fulfilling cases! Truly a practice of patience and trust for our patients. We began the morning with a wonderful reflection on yesterday’s long hard day, how we respond to and recover from, and even grow and garner energy from such an experience. In this type of work, one expects a fair amount of suffering, naturally.

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In fact, if there is no suffering, whether personally or as a whole, it doesn’t really feel like a mission. I found myself talking to Father Em today (Em short for Emerson!) and he told me his story of how he entered the religious life. We reflected on how as young people, we often think of our paths as straight, a paved road to follow, maybe even with yellow bricks! (do people still watch the wizard of oz, or am i dating myself?!)

But in times of calling or being called as it were, we sometimes find ourselves with getting doors slammed in our face. It feels harsh, hateful even, and it feels like we are being persecuted for going after our dreams. In fact what it likely is in reality, is us being guided towards the right corridors. If we were to walk through those doors (reminds me of Monsters Inc!) it would put us in rooms/places we are not meant to be.

Father Em said that this is how he entered, left and then re-entered the priesthood. He thought he was destined for a different life , but God had other better plans, yet to be manifested. How exciting! It is like choose your adventure, only not at all like choose your own adventure! It is like let God choose your own adventure!

Today’s procedures/surgeries were much like this story. Time and again,we are presented with people in need, with perceived expectations from the patient perspective. Similarly we have our own expectations as surgeons. Regardless of either, at a certain point we all realize that there is a higher power at play: the planes of dissection are pointing in a certain direction/order, the case progress is fast/slow, there are areas of lull or slowness dictated by a higher sequence of things over which we have no control.

We often call these things “Murphy’s law” or fate or even “poor protoplasm” as oftentimes they lead to humbling changes in management for the safety of the patient. For example, we had planned to perform a total thyroidectomy on a certain patient this afternoon. After removing one lobe, however, we found that physiologically and anatomically, it would be more conservative and appropriate to forego removing her other lobe. Safety first, and do no harm are some of our mantras. In fact, we say these things as if we are in fact the ones choosing the path we are taking. My fellow surgeon and I in this particular case remarked on the fact that “someone” was telling us to stay away from her right side. We quickly remarked that it was God telling us to do the right thing:)

Day 5

What a day! After a total of 9 cases for us today, we noted that we were able to be home before 9pm! An accomplishment for sure. As it were, it was a medically challenging day. Our oldest patient was 63 years old and her surgery was hard. I plan to monitor her closely overnight. She has no diagnosed medical problems, but as is often the case, this is likely due to the fact that she is not able to go to the doctor for regular visits.

My second most difficult case of the day was a large 6 cm hemangioma behind the left ear of a 17 year old girl. Beautiful young lady, but made self conscious and ashamed due to the large deforming mass visible from almost all directions. It was in this moment that I am so grateful to have a reconstructive plastic surgeon here! Dr Samson Lee helped me plan my incisions and in fact helped assist in the operation. A wonderful cosmetic result followed.

For the first time, this young lady smiled at me! Though she is young, she has already had a rough life. Her father passed away when she was very young, and her mother abandoned her a few years ago because she was unable to support her and her older sisters. She now lives with her older sister but is under guardianship of her school teacher. Her teacher mentioned that she had been abused as a child, as there were various men in and out of her mother’s life before she was abandoned. She has difficulty looking up and speaking as a result. Every move she has ever made has been a nidus for punishment in the past.

Day 6

A busy day. Don’t remember much else aside from our four hernia procedures and two thyroidectomies. Dr Deneve repaired an interesting scrotal hernia which contained omentum and transverse colon! That would be a first for me! The patient stated he had the hernia for a couple of months, though based on the extent, we suspect decades.

For now…sleep…