I'm happy to report that I had my first night on call last night, and not only did all the patients survive, but so did I! The last few weeks I've been hanging around the hospital and getting oriented, but they have had enough surgical coverage that they haven't needed me on the schedule yet, and for that I've been grateful. I've been starting to find my way around the hospital (challenge #1!), and become familiar with how things work around here. I still have plenty of questions and am figuring things out as I go, but there are enough people around who know what they're doing that I have lots of people to ask.
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| Photo courtesy of Paul Sherar |
This week is the first week I've been slotted into the day/night schedule. I had an OR day on Monday. Did 2 laparoscopic gallbladders (known in the surgical world as lap choles), and helped another surgeon with a big burn debridement and skin graft. [By "help," I mean he taught me how to do it.] That patient is a 21-year-old girl with epilepsy who had a seizure and fell into the fire and burned her torso really badly. She'd already had one skin grafting procedure but because of very poor nutritional status and infection, the graft failed, so this was round 2. This is, unfortunately, not the first time she's been burned. Her face is badly scarred from the previous experience, which occurred when she was much younger. Sadly, burns in patients with epilepsy are not that uncommon around here.
The lap choles should have been a piece of cake. Back home, it's a favourite operation of mine. They can be challenging at times, but usually are nice and straightforward, and I can do them pretty quickly. Not here!! We do have a laparoscopic set-up, which is attached to a TV screen that always has that "popcorn" kind of appearance to it. Visualization is not great at the best of times. The equipment works...sometimes. If the electricity shuts off partway through then you really have fun! And even if it doesn't it always seems like something isn't working. It's been pretty warm lately (in the low 30's celcius) and humid, and I was sweating buckets in the OR, and I was also getting really frustrated because I couldn't see and I couldn't figure out why I couldn't see. Was it because I wasn't exposing it properly for myself? Was my assistant not retracting properly? Was my other assistant doing something wrong with the camera? Or was there something wrong with the camera itself? Or all of the above? I don't know, but it was not easy! And then just as I was finishing the second case, taking the gallbladder out of the abdomen, I spilled a whole pile of stones and had to make a bigger incision to get them out. Sigh! That evening I was exhausted, and the next day I was sore all over!
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| Photo courtesy of Paul Sherar |
Then yesterday I was in the surgical outpatient clinic. Thankfully (for me), with the ongoing bandhs, the clinic was very quiet. That gave me time to figure things out as I went. With almost every patient there was some kind of issue that I needed to ask someone about. Either I had a question about how we do things around here, so had to make a phone call or run over to the minor OR where another surgeon was hanging out, or I was struggling to figure out what to do with the medical problem I was confronted with, or just how to interpret the X-Ray I was looking at. There was lots of orthopedics and urology, and very little "general surgery" as I know it. Add to that the fact that I was trying to do all this in Nepali, and we'll just say I wasn't moving very efficiently. The clinic aide was getting impatient with me - I could tell. And then at one point he said, "Doctor, you know it's okay today because of the bandh but usually there are a lot more patients than this and you have to go faster." Easy for him to say! I smiled and said I would try, and in my mind just told myself that it has to be okay for me to be slow for awhile, because it's just the way it is. I'll get faster, but there's a lot I'm figuring out as I go. I had decided when I woke up yesterday morning that I would choose an attitude of thankfulness yesterday, so I thanked God that because there was a bandh it gave me the time I needed to figure things out.
As mentioned, last night was my first night on call. I was nervous, but it was good to finally get started. The more you delay things the more nervous you get sometimes. Best to get on with it. Things went well, overall. I dealt with several things that I'd never dealt with before. Sometimes I'm not sure if I'm teaching the resident or if the resident (who has been working on this service for the past 1 1/2 years) is teaching me! A bit of both, I'd say. And that's just fine. The night started with an appendectomy for a guy with a ruptured appendix - something I know how to do!! Good start. Then we had a guy who'd fallen from a ladder and had injured his urethra. He was passing lots of blood but no urine, and his bladder was getting fuller and fuller. So I took him to the OR and put in a catheter into his bladder through his abdomen (not wanting to make the urethral injury worse). Not a hard procedure, but a new one for me. The resident, who had done it several times, taught me how!
Then we got called to the ER for a man who they said had dislocated his jaw. Great! I have NO idea how to handle that! I went to see the guy and looked at his X-Rays (which I couldn't make heads or tails of). But I looked at him, and thought to myself, "He looks awfully stiff!" I tried to get him to sit up, and he was rigid as a board all over. His jaw didn't really look dislocated (not that I really know what that looks like) - his teeth were just kind of clenched in this funny sort of way. I've never seen or dealt with a case of tetanus before, but I started wondering if that was what we were dealing with and not a jaw dislocation at all. On further questioning, sure enough, he'd cut his finger a few weeks ago, and while it didn't look terribly infected, it could certainly have been the source. We asked the medical (as opposed to surgical) docs to take a look, and they agreed...so he is now being treated for tetanus and we don't think his jaw is really dislocated.
We dealt with several orthopedic injuries, including a compound fracture (where the bone is exposed), but all of them we just temporized and did the initial assessment and care and left for our very capable orthopedic surgeon to deal with in the morning. Thank God we have one! And then there was a lady who'd had a baby a few weeks ago who had stopped breastfeeding on the one side because her baby didn't seem to like feeding from that breast. She showed up with that side about 4 times the side of the other, and when I stuck a needle into it today, I drained a lot of milk out.
This morning there was a 6-year-old kid with a swollen calf, which my clever resident stuck a needle into and found pus. Pyomyositis, or pus in muscle (which I'd never heard of before), is apparently not that uncommon here. I took him to the OR and drained the pus. He should feel better soon.
The political situation remains tense here. Things are open here in Tansen now, after being closed for days, but there are still a lot of demonstrations going on all over the country, and in the southern part of the country there are still very strict strikes going on. Apparently the government has requested another 3-month extension on the constitution deadline, but the supreme court has said no. The problem is that because there is no constitution, nobody even really knows who is in charge, so we'll see who ends up winning the argument. And so it continues! I know a lot of people are praying for Nepal right now, and so we wait and see what happens. In the meantime, some supplies at the hospital are getting slim, and the number of patients who actually come to hospital is also significantly less than usual. Not a bad thing for me right now as I figure things out, perhaps, but not so good for the people of Nepal.
