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Bay Area Surgical Mission – Brian Song, MD

Written by Brian Song, MD, PGY4 at Kaiser Permanente Oakland Otolaryngology Residency Program on a Global Health rotation with Bay Area Surgical Mission in Daet, Philippines.

I was anxious and excited leading up to our medical mission trip. We had a diverse team from across the United States and the two other otolaryngologists I was scheduled to work with were from New Mexico and mere acquaintances. Coordination was challenging requiring lots of emailing and phone calls. Yet, we had experienced leadership within a well-established organization who ensured the logistics proceeded without issue.

The flight to the Philippines was 14 hours spanning 7000 miles. In this modern age, flights anywhere are ubiquitous with standard amenities and service. The moment we stepped on that plane, we could have been traveling anywhere. Therefore, the reality of our upcoming adventure did not come to fruition until we arrived. The Philippines is 16 hours ahead of California and we lost a whole day by the time we arrived in Manila; the closest I’ve come to time travel. It was here at the Manila airport our adventure truly began. We hopped on a small prop plane and took off away from civilization and onto our destination. Our small prop plane landed roughly in Daet and stopped just at the edge of the runway where we could peer over the edge. At that moment, I realized we were in a different land and I could only imagine what lied ahead.

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A warm welcome from the local people from the moment we stepped off the plane.

We only had a week to provide medical care and therefore from the moment we arrived to the moment we left, we worked. On the first day as we unloaded and setup our equipment, the reality of operating in a country with markedly less resources was evident: antiquated anesthesia machines, rolling blackouts, and weak suction vacuums. Operating here would take creativity and much patience. We were all up for the task but a feeling of nervous excitement lingered in the back of my mind. While I wanted to provide as much care possible for the local people, the last thing I wanted was a serious complication.

 

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Operating amidst a rolling blackout.

We also started seeing patients right away. Clinic here was a different experience from the prior medical mission that I was a part of. One quick glance scanning the waiting room and the pathology was grossly evident. Goiters, parotid tumors, and neck masses, these were large tumors that have been growing for a long time. The sheer size of these tumors were much larger than I had seen in residency since they would have been addressed at a much earlier stage in the US. Yet, many of these people have lived with these conditions for several years despite the obvious pathology that they harbored due to their lack of financial resources. As a surgeon, I wanted to help every one of these individuals but one had to be judicious. Imaging was limited and therefore we had to rely heavily on our minds and hands to determine the type and extent of various tumors. In addition, since finances were a significant limitation for many of the patients, we had to limit operations to hemi-thyroidectomies since patients could not afford hormone replacement therapy. This required a thorough history and examination. Even a simple tonsillectomy required much foresight where we only scheduled a few cases on the first day to ensure that we could be around if there were any post op bleeds. Astoundingly, almost every patient we saw had a large head and neck tumor. Within an hour, we already filled the majority of our OR time for the week!

The first day operating started off with a couple of tonsillectomies that we considered as a warm up for the week. We have a common mantra in otolaryngology that, “A tonsil is never just a tonsil.” A tonsillectomy is a common straightforward procedure performed by otolaryngologist and is one of the first procedures we learn as residents. Yet, despite its simplicity, one should always be vigilant for complications that can occur in a tonsillectomy and they can be catastrophic. In the Philippines, we discovered quickly that a tonsillectomy was not a typical tonsillectomy. We did not have our regular mouth retractors or protected cautery devices nor did the anesthesiologist have any paralytic medications to facilitate opening the patient’s mouth for good exposure. We tried various retractors and augmented instruments to fit our needs; not ideal but it worked. With multiple hands retracting the mouth and significantly limiting one’s view, the tonsillectomy proved to be quite challenging but a good introduction to operating in the Philippines. Creativity, patience, and a deep meditative breath became an essential in our daily operative approach.

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Our first look at the OR resources available.

The rest of the week’s cases proved to be just as challenging but proceeded with minimal issues. We adapted with our Zen-like approach to each day. When the power went out taking our ability to cauterize and suction, we packed the operative site and waited patiently until the power returned. When an instrument was not available, we tried using a different instrument or fashioned a new instrument to our needs. When a gurney was not available to transport a patient, we carried the patient ourselves to the post-operative recovery unit. With a positive attitude, we adapted with ease and minimal stress, a trait that I hope to carry with me back to my daily life.

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The local autoclave.

While the big cases proceeded in the OR, we also had a “lumps and bumps” procedure room that we setup in the pre-op area. While the big cases in the OR were rewarding, the small procedures were just simply fun. Here, we worked with the local nursing students who had little clinical experience. Their nervousness and disorientation reminded me much of my early days as a medical student. With every epidermoid inclusion cyst or lipoma we removed, the students’ faces would be aghast but amazed that something like that could grow in our bodies. It was fun finally being the experienced teacher rather than the lost student.

After the cases were done for the day, we had a very active social schedule for the week. Almost every night, we had dinner with the local community members ranging from the mayor to the assistant governor to the local nursing school who also entertained us with a dance performance. I’ve never eaten so much food over the course of a week. Fish, pili nuts, panseet, and balut, I made sure to try it all. And, of course, we ended each night Filipino style with a karaoke session back at the hotel where we were staying.

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A moment to relax a day before we headed back to the US.

By the end of the week, we looked back at all that we accomplished. I will never forget the genuine smile and expressed gratitude that a patient demonstrated to me after she saw her now flat neck after her goiter was removed. I saw a patient’s wife ecstatic to look at her husband’s new face after we removed a large parotid mass. These were the moments in medicine that I looked forward to when I started medical school and I was finally living it.

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