Monsoon

We have now entered the season known in this part of the world as monsoon. What that means is that for a month or two, it rains...a lot...every day. It means that there is mud everywhere, and that clothes don't dry and things get mouldy really quickly. There are usually (but not always) a couple hours of sunshine every day in between bursts of rain, though often it's just grey and drizzly even when it's not a downpour.

The rain has cooled things down a bit, though. The last month-and-a-half have been very hot, with temperatures in the mid to high 30's celcius most days and quite humid. I have been in those kinds of temperatures before, but I don't think I have ever sweat as much as I have here - especially in the OR! I am thankful, however, that I don't live in the Terai (the flat part of Nepal that is south of the foothills). In Butwal, which is less than a 2-hour drive from here, temperatures have been in the mid-to-high 40's! I haven't really said much about the heat, even though it's been quite uncomfortable and leaves you feeling sapped of energy, because I know I had a lot to say during the winter about the cold, and I don't want to seem to be complaining about every season in Nepal. But let's just say that unless you come in March or October/November, you don't come to Nepal for it's weather! One of my language teachers in Kathmandu told me that in Nepal there are 4 seasons: the cold season, the hot season, the rainy season, and the pleasant season. Sadly the pleasant season only lasts for a max of about 2 months total...and I'm going to miss it again this year! Not that I'm complaining about the reason for missing it...I'd rather be at home celebrating my wedding...but still!

The other thing that happens in monsoon, as we're discovering, is that the snakes come out. While Nepal may not be home to the deadliest snakes in the world, there are definitely poisonous snakes around. Pretty much every day these days at least 2-3 people come in having suffered snakebites. Most of them are bitten by green snakes, which release a toxin that prevents blood from clotting. Patients get swelling around where the bite was...sometimes in the entire limb...and sometimes they get into trouble with bleeding, but usually it's not too serious. Then there are the krait snakes, which have a neurotoxin - that is, one that affects nerves, and can cause serious respiratory compromise and death if not treated. We do have antivenom in small supplies at the hospital, and so most people survive. But I'm still very aware these days of where I'm walking, and nervous a snake might show up in my house. They like to come out of the rain into people's homes. One patient was bitten in her own bed in the middle of the night! Her home is just steps from the hospital. I would add prayer for protection from snakes to my list of prayer requests in this season. 

Critters

Today, instead of writing anything medical, I would like to introduce you to some of my housemates. I had planned on living alone here (at least before the wedding!), but I guess God decided I would be lonely, so He's provided me with some company.

Brian is my favourite of my companions. Not sure why his name is Brian...it just is. He has family members, as well, some bigger, some smaller. They are cute, and don't get in my way, and supposedly they eat mosquitoes (more on them later!), so I don't mind them.

Meet Bill. He has a cousin named Bull. In case you're not familiar with Swedish children's literature, Bill and Bull are the evil cats in a series about a cat named Pelle who has no tail. Bill and Bull have died and come to life many times already. For some reason there are always 2 of them, and they stalk my kitchen at nighttime. Before I moved here, I'm told the microwave had 3 dead cockroaches somehow stuck inside the glass of the door. I was given the option of keeping it or having the workshop take it away for me at no charge. I should have kept it, at least to get a photo, but I opted for expedient removal instead.

Meet Shelob. She also has many relatives in my house, some bigger, some smaller. I don't think she's as deadly as her namesake, but I'm still grossed out by her. I'm not sure what was going on with this one...a sac of eggs, perhaps? I found her one morning, sac and all, drowned in a bucket of water in the bathroom. I can't say I was too disappointed.

Meet the builders. They like to congregate in my house, especially in the kitchen, and, for some reason, the bathroom. We all know that ants work hard, and the Bible holds them up as examples for us all. I don't mind them too much...I've just learned not to leave any food lying around, and to rinse all my dishes.

Meet the destroyers. Unlike their relatives the ants, the termites like to demolish homes around here. I haven't actually seen them..just their trails. My didi is forever cleaning up after them.

Then there are the invisible friends. There is the one mosquito that seems to fly in my room every night. I have never seen it, but it whines around my ear, and bites me just as I'm drifting off to sleep. I spent several almost sleepless nights dealing with it until I finally gave in and put up a mosquito net. There is also the rat (rats?) who lives in my ceiling. I haven't seen him, either, but I can hear him scurrying around up there, especially at night. Gross!

Today I found a centipede (or maybe millipede - not sure) in a bucket in my bathroom, but was so grossed out and freaked out by it that I drowned it before I thought to take a picture.

Now, outside, I also have many friends. There are the crickets that Paul can hear every time I talk on Skype with him. (That's how he knows that our skype connection hasn't been lost if we're quiet for a minute or two. In Kathmandu it was dogs - here it's crickets). There are these big crows that, like racoons back home, go after the garbage outside. There are a few dogs, too, but nothing like in Kathmandu.

Directly underneath my bedroom is the sleeping room for the guards on the compound. Every morning about about 5:30 I get woken up by the sound of really forceful horking and spitting...lovely! And then they chat for a few minutes, and move on. Sometimes I can go back to sleep after that, and sometimes I can't.

All in all, it would seem that God is answering people's prayers that I wouldn't be lonely over here. I might have chosen different companions, myself, but His ways are not our ways!

Language fun

Today on rounds I was talking to a patient who was about to be discharged from hospital. She had initially come in with an acute airway obstruction - we didn't know why (still don't really). We did an emergency tracheostomy on her that evening. We think there was something infectious going on, though we never did figure out what. She got better, and her trach is now out, but she developed a really bad pneumonia after it all. She's been with us a few weeks, but today was ready to go home.


As I was giving her discharge instructions, I meant to tell her that if she developed another fever, chest pain, or difficulty breathing, she should come to hospital before her 2-week follow-up time. I said those things to her, and she looked at me and smiled in an amused sort of way. I stopped for a minute, and said, "Wait, how do you say  'breathe' again?" When they told me I realized what had happened. The Nepali word for "laugh" is "hass," while the word for breathe is "sass." I had said "hass" instead of "sass," thus asking her to come back if she developed a fever, chest pain, or had trouble laughing. Oops! 


Some of you have been asking about little Sarik, the malnourished baby who we were worried had a bowel obstruction. Last week we realized there was really nothing more we could do for him, and so his mother took him home, not because he was better, but because we had no more options. She knew she was taking him home to die. I haven't heard any more since then, and I doubt that I will. My guess is that he's probably died by now, but I don't know that for sure and I likely never will. It's hard not knowing the final outcome, and we really don't have the opportunity to truly follow up on how our patients do after they've been discharged from the hospital. Even the ones who left and were seemingly doing fine could have complications we never hear about. And the final pathway for most patients who are dying is that their families take them home. They have other responsibilities at home, usually, and it's expensive to keep people in hospital, so if there's nothing more that can be done, they just go home. Very different than in Canada, where dying in hospital or some kind of institution is the most common thing. In some ways this is more "natural," I guess...just very foreign to our Western minds.


It also makes it difficult for us to know what our surgical outcomes really are. We discharge patients, and then often never see them again, either because they are better, or because they are worse or dead and never come back. Many of them come from quite far away, though we don't, for the most part, hear stories about people walking for days to get here like you do in some places in the world. But to come back requires quite a lot of effort on their part, and so we don't routinely schedule follow-up for most patients after surgery, unless there is something specific we're watching for. They get their wound care or suture removal done at the local health posts (small clinics run by nurses in the rural areas), and we typically don't see them again. Even if we did tell them to come back for follow up, many wouldn't come. It's just the reality of life here. Makes it hard to judge sometimes how well we are actually caring for our patients. But in the end, we do the best we can, and leave the outcomes up to God. It's all we can do, and we pray and trust that it makes a difference in people's lives and in this nation.

2 week tally

I'm doing my best to keep a log of all the cases I do here. It's good for my own information, good for any presentations I may do back home, and also important for potential future jobs, etc. I thought I'd give a run-down of the cases I've done so far:

Inguinal (groin) hernias: 3
Open cholecystectomies (gallbladders): 3
Laparoscopic choles: 3
Removal of a shoulder mass on a young girl: 1
Removal of a supraclavicular (above the collar bone) lymph node: 1
Removal of a stone from a patient's ureter (the tube that connects the kidney and the bladder): 1 + assisted other surgeons with 2-3 others
Removal of a stone from a patient's bladder: 1
Burn debridement and skin graft: 1
Release of a scar on a patient's finger that kept it in a permanently flexed position, and then skin grafting the resulting defect: 1
Emergency tracheostomy: 1
C-sections: 5
Appendectomies: 2
Incision and drainage of muscle abscesses: 2
Emergency suprapubic catheter (tube into the bladder through the abdomen): 1
Removal of a breast lump: 1 (which turned out to be an infection not a tumor)
Pinning of broken bones in hands: 2
Tendon repair in hands: 2
Salpingectomy (removal of fallopian tube) for an ectopic pregnancy (pregnancy that lodged in the tube rather than the uterus and then ruptures and causes major internal bleeding): 1

This has been in the last 2 weeks. Of these, roughly half were things I'd seen or done before, and the rest I hadn't. It's also interesting that none of these have been cancer cases. Back home, a huge percentage of what we see is cancer, especially breast and colon cancer. Here, the one patient who I thought had a breast cancer - she was the right age and it sure felt like one - ended up having an abscess instead. Which is good for her, obviously! But it just highlights the fact that I'm dealing with many different things here compared with back home. Which keeps me on my toes, and keeps me depending on God for help, strength, and wisdom.

Someone sent me this picture a few months back, and I've been aware this week of how much I need His help in what I do. I'm grateful that He is with me, guiding my hands as I do my best to care for the patients that are entrusted to me.