195. Svay Rieng Day Two

The hospital ob-gyn department (I think two, maybe three docs), had patients lined up, so within a few hours I had most of the week scheduled, planning just two major surgeries per day. The surgical team included one general surgeon, two orthopedic surgeons, and one oral-facial surgeon, but just one anesthetist (though we quickly arranged for local anesthetists to help). Moreover, we had no experienced OR nurses. That's because CHPAA formed it's own surgical team, rather than subcontracting out to exisiting surgical teams as they have done in past years and will do again next year.

So it seem reasonable to use just the two rooms offered to us (out of three, leaving one OR room for emergencies such as trauma or cesarean deliveries—though with a published CS rate of just 2% the latter is rare and we didn't see any). In Takeo we placed two OR tables in one of our two rooms so that three cases could be going on at the same time. But this time around two simultaneous surgeries maxed out our nursing support. So one room was devoted to the father-son orthopedic team and room to alternate general surgery and gyn.

First patient, a 40 year old GP with several months of pelvic pressure. A little young for uterine prolapse, but years of hard labor in the fields, and poor nutrition will do it. Similar story for the second patient, but she had something to eat while waiting her turn so was rescheduled for the next day.

194. Svay Rieng Day One

In December, I got a call from Dr. Song Tan, a Cambodian-born pediatrician now practicing in Long Beach and the head of the Cambodian Health Professionals Association of America. For five years CHPAA has sponsored medical missions (dental,eye glasses, prosthetic hands, family practice, and surgical to rural Cambodia. Two years ago I worked with them in Takeo; this year their Ob-Gyn cancelled and Song asked if I could come instead.

Buddhist Monks are great at crowd control.

I had already signed on for two weeks in the Philippines, with the second week coinciding with the one week of CHPAA's mission. You guessed it, I decided to both; better to have one ob-gyn each in different missions than two in one and none in the other.

We flew from Manilla to Saigon to Phnom Penh, then hired a driver for the 4-5 hr ride to Sva Rieng. He came from a village and managed to work as a motorcycle taxi driver.  He saved money, borrowed more from relatives and bought a car.  He's engaged and saving for a wedding, which is very expensive because the groom is expected to put on a big show--as in feeding the entire village. We arrived late Sunday night. Monday morning large crowds were waiting.

193. Dagupan Final Day

Dr. B is sick today (not traveler's gastritis, but a cold with too much coughing to be in the OR). So I manage 3 major surgeries: two vaginal hysterectomies for prolapse and abnormal surgery for a benign (or so it appears, one never knows) ovarian cyst. We are told that there is a pathology department, so all tissue we remove will be looked at under the microscope and if determined to be malignant, the patient will be contacted for follow-up care. Except for my other Philippine mission, none of my other missions have offered pathology evaluation, another sign that the Philippine hospitals where we work are a notch higher. The reality of the follow-up? Don't know.

192. Dagupan Day 6.

Door Number One or Door Number Two?

A very difficult day. My partner promised 37 year old Myra that she would try to remove a large fibroid, leaving the uterus as intact as possible, since Myra still wants to conceive, now 13 years married and never pregnant. Given infertility since her mid 20's, there may infertility factors other than the fibroid which was probably too small to cause infertility problems 10 years ago.

Cervix at the bottom; Fallopian tubes on either side

We start surgery and when the uterus is exposed, we can't tell whether there is a single or multiple fibroids (the latter would make it harder to leave a uterus capable of supporting a pregnancy). So Dr. B. decides to proceed with a full hysterectomy, which she had warned the patient was the most likely outcome, and which went well.

one large fibroid or a few fused fibroids

Afterwards I opened the uterus and found just one, large fibroid (or perhaps a few fused fibroids, though either way, surgical excison not difficult). In retrospect, then, it probably would have been possible to conserve the uterus. But who knows, after another 5-10 years of infertility, more fibroid(s) could grow, causing more problems, requiring surgery again, which may or may not be available.

191. Dagupan Day 5

Today I am the primary surgeon for vaginal hysterectomies, again assisted by the residents. About this time my German-born, Canadian-trained Go-Med partner (her first mission) asks, why are we here? She sees the many skilled residents, a well-equipped operative suite, and the common histories of patients who so far seem to have been experiencing their problems for just a few months. It's not like we are seeing patients who have been on waiting lists for years. The impression being that in out absence, the residents would be providing surgical management.

preop clinic: plastic table and chairs in a hallway

But who knows? Perhaps it's just been in the past few months that clinics have been picking up patients for us; similar patients who presented at clinics six months ago may have just been told to save up money for private surgeons, with only emergencies making it into the system.

The Philippines has an impressive medical system (witness the thousands of the Philippine nurses trained in the Philippines and now working in U.S. Hospitals). But the director of ob-gyn resident training informs me that Philippine health officials figure that the nation is a million doctors short of what is needed, and I assume like everywhere, shortages are greater in rural areas.

The operative suite bears out this suggestion of physician shortage. There are just four operating rooms in the largest (and only?) public hospital in the province. My U.S. hospital, one of the two largest hospitals in the county, has 17 operating rooms. All told, I would guess the county has at least 50 operating rooms.