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Daet, Philippines – Bay Area Surgical Mission – Stephanie Cizek, MD

Written by Stephanie Cizek, MD, PGY3 at Kaiser Permanente San Francisco OB/GYN Residency Program on a Global Health rotation with Bay Area Surgical Mission in Daet, Philippines.

Mary has fibroids.  Common, benign tumors on the uterus, which for her have grown disproportionately large, causing abdominal pain and heavy bleeding with her periods.  She has lost so much blood that she is chronically anemic, and her fibroids have grown so large on her tiny frame that she appears 20 weeks pregnant.  She has had surgery for this problem before — 15 years ago, a group of surgeons on a surgical mission trip landed near Mary’s hometown in the Philippines for a week to provide free surgery.  She has a large 15cm scar across her abdomen, but the surgery initially was successful; now, however, her fibroids have grown large again.  She wants to become pregnant but has been unable to bear children so far.  She is 35 years old, and wants surgery again before it is too late to have children.

I met Mary in a hospital in a little town called Daet, in a rural province of the Philippines.  I am a resident in ob/gyn, and am part a group of physicians from the United States who were invited to work in this hospital.  Mary was in our clinic to be evaluated for fibroid surgery.  The hospital is located over three hours from her home near a mountain known as the Virgin’s Breast; her commute required travel by truck and by ferry.  We represented an opportunity for surgery, for relief from pain and bleeding, and possibly for fertility.

Her evaluation was straightforward enough.  She brought with her the results of her pre-evaluation from the local medical team, who agreed to provide this service free to patients in exchange for a small monetary donation from our program.  She had her latest blood counts with her, a normal chest X-ray, and an ultrasound report with the dimensions of the fibroids.  Her exam confirmed the ultrasound report, but an exam was hardly needed for what you could see at a glance:  her lower abdomen was completely filled by the tumor, extending across from flank to flank, and upwards to just above the belly button.

We discussed, through a Tagalog interpreter, that this fibroid was large and that it would likely be a difficult surgery.  The large tumor was severely disturbing her quality of life, but it wouldn’t kill her.  Her fertility may or may not be helped by removal of the fibroid, and depending on what type of bleeding or scar tissue we encountered in the surgery, she had a high risk of needing a hysterectomy, rendering her totally infertile.  She has had surgery before, and the resulting scar tissue could make the surgery even more difficult.  Her bowel, bladder, and ureters could be stuck in anatomically incorrect locations due to the previous surgery, or just because the bulk of the fibroid is stretching her tissue in abnormal ways.   And our main concern:  hemorrhage.  All tumors, benign or malignant, need a good blood supply to continue growing.  Her large fibroids were likely to have a proportionately large blood supply.  Most healthy patients can tolerate some blood loss, but Mary would start this surgery with blood counts that were already low.

Can she obtain red blood cells for transfusion? We asked.  Our mission trip provides surgery, and to provide that is in itself a monumental effort.  We bring with us a team of surgeons, nurse anesthetists, pre-operative nurses, and post-operative nurses.  Through donations, we collect surgical equipment, antibiotics, anesthetic drugs, and post-operative painkillers, which we bring into the country.  However, items that must be purchased within the country are not provided by our group, and blood products are one of these items.  A pack of red blood cells costs the equivalent of US $30.  Mary needed at least two packs ready in advance.  For many patients, this could be cost-prohibitive.

But Mary said she already has blood.  It was purchased on the recommendation of her primary physician, and she claims she has two units in her name waiting in the blood bank.  She heard and, as far as we were able to tell, understood the risks of the surgery.  She wanted us to try to remove only the fibroids, but even if we found we had to remove her uterus, her fibroids have made her life so uncomfortable that having a baby is less important that just removing the source of the pain and bleeding.

Still, we hesitated.  She was not in an emergency situation, and fibroids are benign tumors.  Wouldn’t it be better if she waited, supplemented her diet with iron pills to build up her blood counts, and returned for surgery when her counts are higher?  It would be safer.  She could save up and have even more blood available.  Our group returns every two years, she could be first in line for surgery with the next trip. No, she said to this.  She wanted the surgery now.

I participated in this trip in the third year of my obstetrics and gynecology residency.  I was a part of the Bay Area Surgical Mission trip to the Philippines, then remained as an observer, shadowing gynecologic surgeons at a training hospital in another part of the Philippines, and then at a small clinic in Indonesia.

In my program in the US, we use state-of-the-art equipment for our surgeries.  We have offered robotic surgery for years; in fact, we just spent hundreds of thousands of dollars to upgrade to a new model.  Our patients expect, and they receive, the most up-to-date care and technology.  I traveled to these developing countries because I wanted to see what surgery could be like without all of our expensive equipment and safeguards.  I also hoped to improve my surgical skills in a place where I knew we would have to rely on larger surgical incisions, instead of the tiny laparoscopic holes that we routinely operate through.  I also wanted to experience a culture that was new to me, and compare their methods to what I was learning.  This is what I anticipated gaining from this experience, and in that regard I got what I came for.

Unexpectedly, this experience also sent me back to the most fundamental question of surgical training:  To operate or not to operate?   In the Philippines and in Indonesia, I found myself constantly returning to this question.  The answer was not always clear.

At a basic level, whether to operate on a sick patient is always the most important question in a surgical field.  But, as the saying goes in medicine:  When you’re a hammer, everything is a nail.  When you’re a surgeon, you wonder with every patient whether you should treat them with surgery, and sometimes it’s just as hard deciding NOT to operate.   As a resident, a supervising physician still sees every patient with me, quizzes me about other management options, forces me to make a recommendation one way or another… And then they make the final recommendation, not me.  More often as I go through training, I can correctly predict who should go to surgery, but still sometimes I am surprised that my supervising physician will make a different call.  There is so much that plays into a decision to operate, and, in this part of my training, I still struggle not to miss important details going into that decision.  And if that decision seems complicated sometimes in the U.S., it is many times more complicated in these countries.

The issue of cost is one of the most obvious factors playing into the decision to operate.   In the Philippines, the uninsured can sometimes still access surgical care through various local and national insurance programs, but with long wait times (up to 6 months for elective surgery).  In Indonesia, there is almost no safety net for the uninsured.  Even in an emergency setting, hospitals often demand payment prior to administering treatment.  In both countries, items that are taken for granted as part of surgical care in the U.S. (such as IV fluids, blood products, and IV pain medication) are often in short supply or simply unavailable.

Also unavailable are many non-surgical management options.  For example, for fibroids, management in the U.S. would often start with hormone injections or hormone implants.  However, these are not always available in under-resourced hospitals in the Philippines and Indonesia.  Although surgery may be more dangerous in those countries than in the U.S., it’s sometimes the only treatment option.

But even when all options are available, sometimes the best answer is surgery.  There is no such thing as a “simple” surgery (complications can always happen), but many elective surgeries in the U.S. can be fairly predictable.  Especially with laparoscopic surgery, procedures that used to be major operations (for example, a simple hysterectomy) are now same-day surgeries, blurring the lines between what is a “major” or a “minor” procedure.  And if there is a complication, you can expect it will be managed in the most up-to-date way with the best technology available.

For a surgical mission trip, there were additional nuances of surgical decision-making.  Mission trips have to choose patients carefully.  A major complication could put a patient in a life-threatening situation; one that, if it required hospitalization past our week in the country, would need care provided by someone other than the person who did the surgery.  Major complications can also foster distrust in the community, which could spell the end of the mission if patients no longer seek us out for care.

Mary’s surgery was planned to be the last surgery for the day.  We had one overhead light to use for two operating tables; we planned Mary’s surgery for a time when we would be guaranteed to have the good overhead light.  Both attending surgeons would be scrubbed in along with me.  We had one pack of red blood cells in the operating room, ready to infuse.  The other one, we were informed, was ready in the blood bank if we should need it.

The surgery was just as complex as we anticipated.  Her prior surgery had left significant amounts of scar tissue.  Her small bowel was plastered to the the top and back of her uterus.  A hysterectomy would be the best, most definitive treatment for her, but we couldn’t safely reach the sides of the uterus (stuck to the side walls of her abdomen) or safely separate the back of the uterus from the bowel.  We decided to just remove the fibroids, noting how the blood vessels feeding the fibroids were engorged to a finger’s thickness in size, thick bands twisting ominously over the surface of her uterus.  We cut a path that avoided the largest of the vessels, but still the tissue bled quickly.

We started the first blood transfusion and called for the second pack to be brought to the OR immediately.  And then the news reached us, news that we should have predicted: there was no second pack of blood.  Mary had been unable to transport the blood she had initially reserved at another hospital, and instead looked to friends and family for last-minute blood donations.  In a weird twist of fate, Mary’s husband’s mistress was the correct blood type and donated the blood.  At the start of the surgery, Mary’s husband was still on the way to the hospital with the blood that had been collected.  A nurse was sent to the entrance of the hospital, and ran the blood to the blood bank for screening as soon as the husband arrived.  Finally, the blood pack arrived in the OR.

And just in time for us.  The fibroids were out, three 10cm sized, egg-shaped masses.  The largest part of the bleeding was controlled and we were sewing the uterus back together to finish the case.  But the operating room was tense.  Mary’s blood pressure had dropped, and the anesthesia team was pushing fluid and medications to try to increase it.  There was palpable relief when the nurse walked in with the second pack of blood.

And that was it.  Mary’s blood pressure improved with the fluids, the medication, and the blood.  We finished the surgery.  She recovered remarkably well.  She stayed for two days in the hospital — in fact, she could have gone home on the first day, but she didn’t want to make an 3 hour evening trip by truck and by ferry, which made sense.

To operate or not to operate on Mary?  Even in hindsight the answer is not quite clear.  Her uterus is scarred and distorted — it’s unlikely she will ever become pregnant, but it’s still possible.  If she does become pregnant, it is likely to be a complicated, risky delivery with all of her scar tissue, and we strongly reinforced that she needs a cesarean delivery.  Her pain and bleeding will likely improve, but she still has fibroids — we removed the largest fibroids, but there were several very small ones, and in the setting of the bleeding, we chose to cut our losses.  She was happy with the surgery, and at least she no longer has to carry the enormous bulk of the fibroids we removed.  Although the last news of Mary is that she is recovering well, she is still at risk for late-appearing complications.  And the episode of the missing pack of red blood cells left us all anxious, and was testament that we were still outsiders, that we still couldn’t predict where land mines may lay in this medical system that is foreign to us.  In retrospect, I’m glad our surgery was able to offer some relief of her symptoms.  But this was not a curative treatment, and the reality is we may never know for certain if we made the right call.

To a hammer, everything looks like a nail.  The goal of every surgery is to finish.  There’s nothing more dangerous than a bored surgeon.  All bleeding eventually ceases.  We try to boil down the chaos of this field into short, witty aphorisms, but in the end the business of surgery defies quick one-liners.  It is a complicated, strange, and wonderful art, no matter where you are in the world.

 

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