Change of Address

Since I'm now married, it is no longer only Dr Jessica who is in Nepal. We have therefore changed our blog address to:

paulandjessicainnepal.blogspot.com

You can continue to follow our journey there. We head back to Nepal January 10, and to Tansen on January 17.

The comforts of home...

As I prepare to leave Tansen on Wednesday, I'm starting to look forward to a lot of things back home. Don't get me wrong...I love it here, and am really glad that I'm not leaving for good. But there are things from home that I really miss and am going to enjoy immensely when I get home. Things like:

• Electricity that stays on
• Tap water that you can drink and brush your teeth with
• Showering in a tub instead of in a bucket in which you collect water for flushing the toilet
• A toilet that flushes
• Fresh fruits and vegetables that I don't have to soak in iodine first
• A house that is (mostly) free of critters, instead of shared with big spiders, cockroaches, geckoes, ants, termites, rats, and other pleasant things
• A lack of venomous snakes (not that I've seen any yet, but they're definitely around, and I'm constantly on the alert, both in my house and out of it)
• Truly high speed internet
• Good chocolate
• Going out for coffee
• Sleeping without being awakened at 5:30 am by loud "throat clearing" and spitting (also known, in my mind, as horking)
• A house where people aren't constantly looking in the window at me
• A language that I easily speak and understand
• Crossing the street without fearing for my life
• Driving a car
• Streetlights (even with a flashlight it's really dark if you have to go anywhere at night off the hospital compound)
• Fall colours

And of course, the most obvious...seeing Paul again after 6 months! Getting married! Seeing friends and family that I haven't seen in almost a year. And many more things.

I'm not really complaining. Life here is actually pretty comfortable, and I enjoy the community here quite a bit. And you can't top the scenery! But I am looking forward to this time back home. I leave Wednesday from Tansen. That'll be a 10-hour busride to Kathmandu. Pray that there are no landslides or troubles on the road, as there often are during the monsoon. I'm spending a week or so in Kathmandu getting final alterations done on my wedding dress. Then on Sept 4 I fly from Kathmandu, and am back home Sept 5. Paul leaves Mozambique on Sept 2 and gets home Sept 3. Then we have a month to get ready for the wedding. At this point we're planning to come back to Nepal sometime in January. That will give enough time to get my documents with my new name on it, and for us both to get our visas for Nepal (mine will have to be reissued, because my name is different). We're looking forward to spending our first Christmas together at home with our families, as well.

Momos

Hard to believe, but one week from today I'm leaving Tansen, and two weeks from today I'll be back in Canada for the wedding. It seemed so overwhelming six months ago when Paul left Nepal to think about being apart for all that time, and now here we are. I'm very thankful...it's been a good six months, but I'm SO ready to move on!

As things are winding down for me here, at least for the next few months, I've been invited out for lots of dinners and other things, which has been nice. Last Friday I organized a momo party for the surgical team (interns, residents, and "senior" doctors, which includes me). For those of you who haven't heard of momos, they are basically dumplings...a Nepali version of the same dumplings that can be found in a lot of countries in Asia. You have some sort of outer dough, or pastry, then fill the shell with either a meat or veggie filling, and then steam them (in a steamer like in the picture below). At a true momo party you all get together and make the momos yourselves, so that's what we did. We had lots of fun, though I'm not sure the momos were all that delicious, since I made the fillings and had never done it before. I had told people we'd start making them around 5, and of course, as per Nepali standard time, no Nepalis showed up until about 6:30. By then the few of us bideshis who had arrived on time had made some momos, but we didn't really know what we were doing.

At 6:30, Dr Shristi, our excellent anesthetist, showed up and immediately told us our momos were way too big. She proceeded to show us how it's done, and after that things went much more smoothly.

Then Prasan, one of the residents, came, and he apparently had made momos every weekend during his medical training, so he was an expert. The batch that he's holding were our pathetic attempts, and they were huge!

Later, Anu, one of the interns, also came, and she was a momo-making machine! She rolled that dough into perfect little circles so fast we couldn't keep up, and then shaped them into these lovely looking things. 

The kids also had fun making momos, and they went beyond the usual momo shape, making "ninja momos," and other creative ones, including an octopus.

So we made and ate momos, and enjoyed ourselves immensely. And afterwards we had a musical jam session, where Samir, another resident, had brought his guitar and I'd brought mine, and we played and sang a bunch of Nepali (and some English) songs together. Great fun!

Best Hospital

I forgot to write about this a couple weeks ago when it happened, but Tansen was recently awarded the "Best Hospital" award for 2012 by a Kathmandu-based health magazine. Dr Rachel, our medical director, went to Kathmandu to receive the award, and a whole lot of people gathered in the Tansen Guesthouse to watch the broadcast on TV.  Unfortunately I was on call, so I missed it, but by all reports it was a great event, and a real boost to hospital staff morale, both bideshi and Nepali.

Here's the article from our hospital website that talks about it:

A few weeks ago a journalist called the hospital and said he would like to interview the director about an award.  It was a complete surprise when he told us that this hospital had been awarded the Best Hospital Award from ‘Swasthiya Kabar Patrika”, a monthly health magazine.  This is a national award and the selection committee had evaluated various nominated hospitals before deciding that ours was best.

The annual Health Awards ceremony was held at the Everest Hotel in Kathmandu on the evening of Sunday 22nd July and was broadcast live on Nepal TV. It was almost like a mini Oscar awards ceremony! Eight different people received an award to recognize their contribution to specific areas of health in Nepal.

"And the award for the Best Hospital goes to... United Mission Hospital Tansen."

It was a proud moment for Rachel Karrach, as the Tansen Hospital Director, to go up on the stage and receive the award from the Minister of Health on behalf of all the staff at the hospital who work so hard.  There was an opportunity for Rachel to say a few words about what makes this hospital different. In her acceptance speech she was able to tell people that our motto is “We serve, Jesus heals”.  We want the glory to go to Him for our success, and also give thanks to all the hospital staff, whose faithful service has enabled this hospital to be the best hospital in Nepal.

Many hospital staff and local Tansen people were watching the program on TV and everyone was very excited that our work had been recognized and that this has put our town on the map.  It was so encouraging and affirming for the hospital's (and UMN's) almost 60 years of service in Tansen to be recognized and applauded.

For photos of the ceremony, please use this address:  http://www.umn.org.np/new/view_album.php?album_id=30

On another note, here are some photos I took in the OR the other day, just to give you all a flavour.

Chandra is our OR charge nurse. Here she is checking out the white board with the list of cases for the day. It's a pretty quiet day in the Tansen OR by the looks of it - often the board is full! The printing is pretty small, but here is the list of cases for the day:
Ortho:
Open Reduction Internal Fixation (ORIF) Supracondylar fracture (1 1/2 year old child)
ORIF Supracondylar fracture and distal radioulnar fracture (7 year child)
ORIF distal radius (6 years old)
Lateral Condyle fracture ORIF (8 years old...yes, it does seem like a pediatric service today!)
ORIF finger fracture (?age)
General Surg:
2 pediatric hernias (that were already done so erased from the board)
Interval appendectomy
Right partial, possible total, nephrectomy (removal of kidney for big symptomatic cyst)
Debridement hand infection (this hand won the "worst hand in the world award" - awarded by ME!)
Foot laceration debridement

This board tells us about the availability of blood in the blood bank, as well as whose OR and on call duty it is that day. How do we stock our blood bank? Well, every patient who needs an operation has to have a family member or friend donate one unit of blood to the blood bank before they can have their surgery, unless it's an emergency, or a really small operation. And hospital staff blood types are also fairly public knowledge...you may just get a call in the middle of the night if there is an emergency need for your particular blood type. Hasn't happened to me yet...

We do have anaesthetic machines, and use halothane gas when a general anaesthetic is needed. We have one Nepali MD Anaesthetist, and the rest are all nurses who have done anaesthesia technician training. They're very good at what they do, and we train people here (the guy who is "bagging" the patient is a student, and the guy in the blue is one of the senior technicians). We don't have ventilators in the OR so all patients with general anaesthesia have to have someone sitting there "bagging" them throughout the case. We do a lot of cases under spinal or other regional anaesthesia to avoid this.

Sita is one of the OR nurses. Today she is staffing the recovery room. There are 2 "monitors" in the recovery room, where you can measure oxygen saturations and heart rates. But there are many more beds than that! 

Repairing a supracondylar fracture on a young girl. The assistant is one of the interns (in her last year of medical school, essentially the equivalent of a clinical clerk back home), and the main surgeon is a guy who finished his internship here at Tansen and then stayed on as a "Resident Medical Officer" in orthopedics. He has been here almost 2 years, and is functioning very capably and often independently. He is in the process of trying to get into a "proper" orthopedics residency training program, but there are many barriers to this, and the extensive experience he has gotten here will not be counted at all towards his training requirements. We have a couple doctors like that at the moment (the other is on General Surgery, and is also excellent). It's really difficult to get residency positions in Nepal unless you know someone and/or have a lot of money! Many end up going elsewhere (often to China), where it's easier to get a training spot, but the training isn't as good. It's really too bad, because some of these doctors are fantastic!

Duttali

Last Friday Duttali was one of the patients I saw in clinic. She is 14 years old, but looked more like 7 or 8. Her father carried her on his back, and she wouldn't make eye contact at all. She was born with spina bifida, where the last part of her spine didn't form properly in utero, so she has a big bulge on her lower back where the membrane around her spinal cord bulges out. She is paralyzed from the waist down, and has no bowel or bladder control.

Amazingly, although her family is very poor, and she is the 4th of 5 children (the other 4 all being "normal" children), her father (the only family member I met) obviously cares very much for her. This is somewhat unusual in this culture. He had brought her to us to see if we could remove the bulge from her back. Unfortunately this isn't possible, at least certainly not here in Tansen. But she also had several pressure sores on her lower limbs, including 2 huge ones on her left ankle that were in rough shape. I could smell them before I even took her bandages off, and when I did, there were maggots crawling in the wounds. Her foot was barely attached because the wounds were so big (sorry for the graphic-ness!). I told her father that there wasn't anything we could do for the bulge in her back, but that her wounds were in rough shape, and she probably needed an amputation of that foot/lower leg. Since Duttali doesn't really walk (she crawls a little bit at home, apparently), an amputation wouldn't really be debilitating for her, and so he agreed to go ahead with it.

For the first 3 days or so in hospital, I never saw Duttali smile or make any eye contact. Her father also was pretty quiet. When I took her to the OR on Sunday for the amputation, she cried and cried until she was put to sleep. The next day, though, her father had big smiles for us, and the day after that so did Duttali. I'm guessing that her father was happy that her leg at least didn't smell bad anymore, and when they saw the stitched up surgical wound it was clean and healthy, and that must have been nice for them. But really, I'm not sure that explains the change we saw in them. I'm guessing they came to a place where they were cared for, and where Duttali was loved and treated with dignity. This is her yesterday when I discharged her from hospital.

It really warmed my heart to see her smile, and to be able to make her laugh. When I showed her her own photo and told her she was beautiful, she beamed from ear to ear. Her father was pretty tickled, too. I pray that during their time here they haven't just known the care of other human beings, but also the love and care of the God who created Duttali and loves her very much.

36 Hours

I would like to walk you all through the 36 hours from Thursday morning to Friday evening this week. I did a total of 16 surgeries during that time...a record for me, I think!

Thursday Morning (my on-call day):

Case #1 - 8-year-old boy who had bilateral (both sides) inguinal (groin) hernias. I repaired these

Case #2 - 54-year-old man with a right inguinal hernia, which I repaired using mesh

Case #3 - Removal of a cyst on an 8-year-old girl's lip

Lunch...which was interrupted by a phone call telling me that there was a young woman with a ruptured ectopic pregnancy (where the pregnancy gets lodged in the fallopian tube rather than the uterus, and then eventually ruptures and causes life-threatening bleeding in the abdomen). So...

Case #4 - Emergency laparotomy (opening the abdomen) for ruptured ectopic pregnancy - she was actively bleeding, and there was about 2.5 L of blood in the abdomen

Case #5 - Circumcision on a 13-year-old boy

Case #6 - Excision of a choledochal cyst (bile duct cyst) on a 13-year-old girl. I assisted another surgeon who did this. We finished around 6 pm

I was then informed that there was a child with a buttock abscess that needed to be drained, but he'd eaten at 2 pm, so we couldn't do it till 8 pm. Fine...time to go home for dinner

Case #7 - Drainage of a buttock abscess on a 4-year-old boy. There was a lot of pus for such a little guy!

Nothing much else going on, so I went home. Got one phone call telling me I had 9 cases scheduled for the next day (9?? Last I checked there were 4, but okay!). Went to bed. At around midnight I got a call for an emergency C-section...

Case #8 - Emergency C-section for a placental abruption (where the placenta separates from the wall of the uterus before the baby is born, causing bleeding that is life-threatening for both mom and baby)

So I was up for an hour-and-a-half or so in the middle of the night, but otherwise slept the rest of the night.

Friday morning:

Rounds took longer than usual because several patients had been admitted from clinic yesterday, and they all had to be sorted out. There was another surgeon operating yesterday as well, and we split up the 9 cases. My morning cases in the OR went very quickly.

Case #9 - Removal of a rectal polyp on a 4-year-old boy

Case #10 - Repair of an inguinal hernia/hydrocele on a 4-year-old boy

Case #11 - Removal of a cyst on a 30-year-old woman's buttock

Case #12 - Removal of a fibroadenoma (benign breast lump) on a 20-year-old girl

Lunch

Case #13 - Laparoscopic cholecystectomy (gallbladder removal). First the light source for the camera wasn't working, so I thought I'd have to do it open instead. Eventually we got it working. Then I got into some bleeding and the suction wasn't working. I almost had to open then to control the bleeding, but then the suction started working, and I was able to get the bleeding under control. Then the power went out, and so we had to stop working until it came back on, which took a few minutes. (At least that only happened once. During a lap chole last week we had 3 power failures!).

Case #14 - Open cholecystectomy. I'd been planning to try it laparoscopically, but I knew there was a high chance of needing to do it open, because it was acutely inflamed. After the lap chole I'd just done I decided it would be safer just to do it open from the get-go

Case #15...well, I thought it was going to be case #15...it was a 34-year-old man who had been admitted a month or so ago with bad pancreatitis (inflammation of the pancreas). He'd been discharged home, but came back with lots of pain, high fevers, and a big mass in his abdomen. It looked like an infected fluid collection on his ultrasound. Back home we would do whatever possible NOT to operate on someone like this, but here we don't have the high-power antibiotics, the interventional radiology, the ICU, etc, that allows us to avoid surgery. So the plan was for me to drain his infected fluid. The nurse anaesthetist had just put him to sleep when we got a call saying that there was an emergency C-section that needed to be done. So he stayed asleep in the one room while the anaesthetic technician student "bagged" him (i.e. breathed for him by pumping on a bag...we don't have ventilators in the OR), and I did...

Case #15 - Emergency C-section for someone who'd had a previous C-section who was having tenderness at the site of her scar (a sign of possible impending uterine rupture). The uterus wasn't ruptured, and baby was fine.

So then I went back to the other room for...

Case #16 - the guy with the infected pancreated fluid collection. Tried at first to just make a small hole and put in a drain, but it was a big mess in there and that wasn't possible, so he got a laparotomy. We'll see how he does...it's going to be a long recovery for him!!

I finally got home at about 8 pm last night, and, needless to say, was rather tired! But such is life as a surgeon sometimes...

A mountaintop experience

Okay, well, really here it's more of a hilltop experience. But these foothills sure seem like mountains to me! The nice thing about monsoon time is that when the sun does come out, usually the air has been cleared of all the dust, so you don't have the haze that settles over the place most of the rest of the year. This morning it was a lovely sunny morning, and I decided to climb up Shrinagar, which is a hill that has about 500 stairs leading to the top of it. The stairs start just above the hospital. There's a great view from up there. I was hoping to see mountains (like real, snow-peaked mountains) - I haven't yet seen them here in Tansen. That wasn't to be. But I did see some amazing clouds (one of the other things that comes with monsoon), and a couple other things...

Below you can see "shantytown," which is the set of dwellings just outside the hospital compound (the hospital is the building on the far left with the red roof).

And here's shantytown again, with the view behind it. Tansen really is a beautiful place!

These last 2 photos were the highlight for me. The first one to me looks like a window into heaven, and reminded me of 1 Corinthians 13:12 about how we only see and know in part now, but there is more to come.

As I sat in a little gazebo-like tower at the top of the hill, I saw this eagle flying very close to me. The picture is a bit blurry, but I almost missed capturing it at all, so I'm glad I got it. Later, another eagle was also flying, a bit further away, and then finally they both came out together and were soaring over the Tansen valley for quite some time, spiralling higher and higher. It was a pretty awesome sight!

"Even youths grow tired and weary, and young men stumble and fall; but those who hope in the Lord will renew their strength. They will soar on wings like eagles; they will run and not grow weary, they will walk and not be faint." -Isaiah 40:30-31

Hands

I'm very happy to note that the countdown to the wedding timer now has less than 100 days on it! It still feels like it's taking forever, but 2 digits is much better than 3...

Yesterday was my first day back at work after a week in Kathmandu. It was a good week away. I had some good R+R time, spent a few days back at the children's home, and also accomplished quite a bit of wedding-related shopping. Kind of fun doing that over here, once you get over the stress of realizing you need a bit more creativity to find things than you would back home.

I knew from the schedule that I was supposed to be operating yesterday. I wasn't sure what I'd actually be doing, since I hadn't been around to schedule any cases for myself. Not that that's ever been an issue...I always seem to end up with a full day of operating, even if at the beginning of the day it's a blank list. Yesterday was no exception.

I started with a lap chole (laparoscopically removing the gallbladder). I'm happy to say that I'm getting used to the suboptimal equipment here, and now I don't mind doing lap choles so much. I hated them at first. We have graspers that don't grasp, suction that only sucks sometimes, a cautery cord that keeps falling off, irrigation that sometimes irrigates, and a camera with a light that is so dim that the only way you can see clearly enough to know what you're doing is if it's so close that your perspective gets a bit distorted! Add to that the fact that more often than not the patients have had several attacks, and their gallbladders are quite inflamed, and you have quite a challenge on your hands! But I'm getting used to it, and now it's not so bad. The one yesterday ended up being a pretty easy one. Mind you, we didn't get started until about an hour after we'd scheduled to start. Despite the fact that it was the first case on the list, the equipment hadn't been sterilized yet.

After that it looked like I had nothing else to do, so I asked the other general surgeon in the OR if he wanted me to do any of his cases for him. I debrided a nasty arm wound for him. Then I noticed that  the orthopedic surgeon was holding a black case that looked an awful lot like my loupes (surgical magnifying glasses) case. I thought maybe he had gotten loupes from the same company as I had, but no, in fact, they were my loupes. I asked him what was up and he said he had a patient with a bad hand injury where he was pretty sure the ulnar nerve (which supplies sensation to the last 2 fingers, and movement impulses to several hand muscles) was completely cut. It needed to be repaired, but that's the kind of thing you need loupes for. Actually, really you need a microscope, but that's not an option here. I told him he was welcome to use mine, but my prescription is so ridiculously strong that they probably wouldn't be of much use to him. He tried them on and promptly agreed...

So then he asked, "Do YOU want to do the case?" My first response? "Ummm...sure." My second response? "How do you repair a nerve?" Simple...you find the 2 ends, then find the tiny membrane around the nerve fibers, and sew it together using a stitch that's as thin as (or thinner than!) a piece of hair. "Sure, no problem," I said.

I decided that after lunch would be a good time for me to do it. No sense operating on an empty stomach, right? I also thought that would give me a good opportunity to go home, and pull out all my books and pictures on the hand, and specifically on the anatomy of the ulnar nerve in the wrist :)

After lunch, I got started. The person had somehow fallen while holding a sickle, and had a huge cut to her palm, extending into the wrist. It had severed several tendons, as well, but they had already fixed those (this was her 3rd trip to the OR). I started exploring where I thought the ulnar nerve should be, and found the end on the side of her wrist. It took me a lot longer to find the other end (on the side of her hand), but eventually I did...or at least, I thought I did...but why were there 2 things that both looked like cut ends of nerves? Hmm. From my review of anatomy, I knew that the ulnar nerve splits into superficial and deep branches right around there, so I figured I had found them both. And then on closer inspection, I realized that the end of the nerve I'd found on the wrist side actually split right at the end, so I could see where they both had to go. Fortunately they came together nicely without much tension, and so I did my best to repair them. It was my first time working with such a fine suture (8-0 nylon, for any of you surgical folks), and it was tricky, but the loupes sure helped. We also didn't really have the type of fine instruments you need to work with a suture that small. Well, we sort of did, but the needle driver didn't really grasp the needle well. So I alternated placing the stitch with the bigger needle driver, and then tying the knot with the tiny one.

In the end, it looked pretty, anyways. Someone did take a photo, but not on my camera, so I can't show it off. It may be months before we know if it worked or not. Nerves take a long time to regenerate. As the orthopedic surgeon said, "We do our best...and trust God for the rest." Absolutely...and so I'm praying that this nerve heals.

Then, because I'm apparently becoming the hand specialist here, along came another patient with a cut injury, also from a sickle (a VERY common injury around here), this time on the back of his hand. It had managed to cut right through the bone leading to his index finger (and it turned out it was in several pieces), as well as the 2 extensor tendons to that finger. I cleaned up the bone edges, and then worked for a long time to figure out how they go together...it was a puzzle, and it wasn't really obvious this time. Then I drilled a wire into the bone to hold the pieces in place as best as possible, and closed the tissue overtop. The bone part was the hardest part. The tendons were cleanly cut, and the repair wasn't too difficult.

I was quite proud at the end of the day, because hand stuff is pretty complicated, and something I have very little experience with. So far I've done a few cases, but always with someone more experienced around helping me. Yesterday I was on my own, but I think it went okay. Though, as I say, we'll have to see what the long-term results are.

In other hospital news, there has been a run of cases of mushroom poisoning here. I actually read about it in the Kathmandu newspaper before I came back. It's now become quite a public thing, and the other day when 6 more patients with mushroom poisoning (all from the same village) came in, multiple people were there, including the press. It became a bit of a crowd control problem. So far, 4 have died (and 3 were young children all from the same family). The poison in these mushrooms is bad...it causes the patient's liver to fail, and there really is no antidote. I'm told that back in 2004 there was something like 40 cases of mushroom poisoning that came in during the monsoon season. Of those, maybe 13 died, which actually isn't even a high percentage (the books quote up to a 60% mortality rate from eating these mushrooms). Nasty!

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.

This and That

Last night at 11:59 was the deadline for the completion of the new constitution. The government had requested another 6-month extension a few days before that, and the request was denied. A lot of people thought that they would pull something together at the last minute, but they announced last night that they had not been able to agree on the most contentious issues, and therefore the current government (known as the Constituent Assembly, or CA) is dissolved, though I think they may remain in quasi-power until the elections, which are set for November 22. What the next 6 months will look like nobody knows. And then it will be the job of the newly elected CA to write the constitution. Will it be a repeat of the last 4 years? Time will tell. For now things are reasonably quiet in the country. No protests have been reported yet. We'll see if things settle back to "normal" for awhile now, or what happens. If you're interested, here is one article that describes the situation somewhat, though I must say that news reporting in Nepal leaves something to be desired, and nobody really knows what's going on.

Life at the hospital seems to be more or less normal at the moment, with the usual volume of patients. I did have one man admitted when I was on call the other day who had been burned when he tried to drive his truck during a bandh and the protestors poured gasoline on his truck and set it on fire. Fortunately most of the burns are pretty superficial. But that's the sort of thing that happens when you break the protestors' rules. If you behave yourself they generally leave you alone. A few days ago we'd been told to be prepared for a curfew to be imposed at any time, in case things got out of hand around the constitution deadline. But that doesn't seem to have happened.

I was on call on Saturday, and had a busy day but a quiet night (which is a nice way to have it). The day started with an emergency C-section, and then we took a guy to the OR who'd had some kind of tractor accident and mashed up his hand. The resident and I worked away at it for awhile, cleaning the ends of his broken bones, cutting away dead/dirty tissue, and trying to find the ends of his tendons that had been severed. In the end I was feeling way over my head (hands are complicated!), and decided that, especially because of his high risk of infection, we should just wash, control the bleeding, splint it, keep him on antibiotics, and come back the next day with another (more experienced) surgeon to try to fix things. Which was just as well, because yesterday the other surgeon and I took him back to the OR, pinned his broken bones, and in the end decided that his tendons weren't fixable right now. So we put him back in the splint, and we'll probably send him to the leprosy hospital in Kathmandu later for a reconstruction. They are experts at tendon repairs and grafts there - they do it all the time for their leprosy patients.

Later on Saturday evening, a little 6-month-old baby came in. He had weighed 2.5 kg at birth, and weighs only 3 kg now. He'd had surgery at birth to form a colostomy because of a congenital problem that left him without an anus. Apparently he'd been doing okay (though not gaining so much weight) until 15 days ago, when he started getting sick and showing signs of bowel blockage. On further questioning, it turns out that his mother's breast milk supply hadn't been adequate, so he'd mostly been drinking buffalo milk for the last few months, which could explain his malnutrition. He was very sick when he came in - dehydrated, his belly really distended, and skin and bones. His bowel isn't completely blocked, and he certainly isn't in any condition for an operation right now - he wouldn't survive it. We are trying to get him some nutrition, but it's tough when he keeps vomiting. Things don't look too good for this little one. I pray for him every day when I go by. His young, hopeful mother, keeps looking at me and asking if it will be okay. I tell her we are trying, but that his condition is very serious, and that we need to keep praying. She nods every time I say that.

I must confess that most of the time I feel out of my comfort zone in one way or another. The language is a challenge, though thankfully there usually is someone around who can help me with translation when I get stuck. I share a lot of smiles with my patients and their families when I try to speak Nepali with them and fumble for one word or another. I'm thankful that most Nepalis are gracious and friendly, and most seem to appreciate that I try to communicate with them. Then, of course, there are more medical/surgical problems that I'm not familiar with than those that I am familiar with. It keeps me on my toes, for sure. The other day the resident and I were doing a tendon repair and pin fixation of a broken bone on another injured hand. We were both kind of fumbling our way through it. Thankfully our nurse that day has been a nurse in the OR for 23 years, and he has seen a lot of these sorts of surgeries. He basically walked us through it! It can be very unnerving to know that in a lot of the things I'm doing here, where I'm supposed to be the supervising and "in charge" physician, the nurses and the residents have more experience than I do! But if you can get over that, swallow your pride, offer the expertise and thoughts that you do have, but listen to their suggestions, it can be very rewarding. The other day I thanked the resident I'd been on call with for his help, and he said, "No, thank YOU for your teaching." I'm thinking, "Teaching? What teaching??" And I said, "Well, I teach you some things, you teach me a lot of things." To which he responded, "No, you teach like a senior doctor, the way I need to be taught. I just help you with the things I know because I've been here doing this for the last 1 1/2 years, but you have a lot to teach me." That's the kind of attitude that will make for a mutually rewarding working relationship!

I'm still taking Nepali lessons, but only once a week for a couple hours. Between studying Nepali, reading up on the many surgical things I need to read up on, building relationships here, and maintaining long-distance communication and wedding planning with my man in Mozambique, I'm being kept pretty busy. It's a bit of a roller coaster ride at times, but I'm thankful to be here, and thankful for all the prayers and support of people here and back home, without which I'm sure I wouldn't last long.

Off to the races

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.

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!

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.

Life is crazy in Nepal

These days, there seems to be no such thing as "business as usual" in Nepal. Maybe that's always the case, but it's crazy right now! May 28 is the deadline for the government to finalize a new constitution for the country. They have been working on it since the middle of the last decade, when Nepal became a republic (democracy) instead of a monarchy. There have been numerous previous deadlines for its finalization, but they have never been met. There have been 6-month extensions, 1-year extensions, and it just seems to keep going. I was actually in Nepal for the previous deadline - Nov 28. At that time they extended it for another 6 months (which, as a side note, means that I have now been in Nepal for 6 months...to the day, today, actually), and said that if it was not completed by that time, a new government would have to be formed.

It was looking promising...sort of. One of the biggest issues had to do with getting former Maoist soldiers rehabilitated, and steps have been made in that direction. But there are SO many parties, with SO many demands, and it's getting more and more ugly as the deadline approaches. Nepal needs a miracle.

What do I mean by ugly? Well, as you've all probably gathered by now, the main method of protest in Nepal is to call a bandh, or strike. Pretty much anyone can call a bandh, and they decide how far-reaching it will be, and how strictly it will be enforced. These days there are bandhs happening everywhere, it seems. In the far west region of Nepal, the poorest, most remote part, they are currently on day 20, I believe, of a very strict one. Everything is shut down - the roads, the schools, the businesses. The situation out there is getting rather desperate for people...increasing food and fuel shortage, and just general misery, probably. Usually when a bandh is declared it is given a time frame. This one is indefinite, and there seems to be no sign of it letting up any time soon.

There have been a couple of nationwide bandhs where everything across the country is shut down, and they have been enforced quite strictly - more strictly than usual. Apparently starting tomorrow there is an indefinite nationwide bandh starting. Who knows what that means? In the Terai (the flat, southern part of Nepal that borders India), there has been one going on for quite some time. For people coming in and out of Tansen, travel through the Terai is usually necessary, though usually you can take a detour around it and go through Pokhara instead (adds an extra 4 hours to the drive). But now there's also a strict bandh in Pokhara. So we actually have some people who are sort of stranded here right now. One of our residents did manage to make it back from Pokhara to Tansen last night - but only because he travelled at night. You can imagine that nighttime travel has its own dangers, when you're driving along these narrow, winding mountain roads with no guardrail!

Our patients are affected. We have discharged some from hospital, but they can't leave because they can't get home. Or they have to stay in a "hotel" here in Tansen. Patients who are already in financial hardship because of their hospitalization...hospital bills, plus they are missing their income because they're not working...now are even more so, because they have to keep paying for lodging and food here, and still can't work.

I wasn't directly involved in any of these cases, but I'm told that yesterday 2 patients who came to the ER were dead on arrival, and another died shortly after arrival. That happens sometimes...but we all wonder if it has to do with the fact that people are waiting longer to come to the hospital because they don't know if they can safely get here. And we're concerned we may see more and more of this over the next few weeks. Yesterday in clinic we didn't know what to tell people about when to come back for follow up or test results. Usually pathology reports (which come from Kathmandu) are available within a month, but who knows when they will be available under these circumstances. Dr Doug, one of the other surgeons here, started telling people to come back for follow-up after the constitution was written. We all laughed at that one...will they EVER come back?

Usually ambulances and hospital vehicles can get through the bandhs okay, but I heard of an ambulance (carrying a patient in it) being vandalized somewhere down in the Terai the other day. Some friends who did manage to make it from Kathmandu to Tansen the other day (but are now stranded here for the time being - they were supposed to leave today) said that there are roadblocks (trees, rocks, stones, and lots of people) all along the way. They did let the hospital vehicle pass through them that day, but it sure took awhile to clear the block so they could even get through. I'm told the hospital vehicle didn't leave for Kathmandu today as it usually does on Wednesdays.

Here at the hospital we see the impact of all this on our patients and their families. And on people trying to get here or get out of here. But we don't (at least at this point) have any concern for our own safety, thankfully. But Nepal is suffering right now, for sure, and whether these demonstrations will accomplish anything or not remains to be seen. At this point they are accomplishing a lot of hardship and difficulty for the people of Nepal. Will they have an impact on the decision-making process? Time will tell. And what will things be like after May 28? If the constitution deadline is NOT met, what will happen? And even if it IS met, there is sure to be ongoing discontent. It may be a rocky ride for awhile.

Please pray for this nation, that God would move the mountains, and establish righteousness and justice as its foundation. Pray for protection and peace for all those who are affected by all that is going on. It all seems impossible, but we also know that God can do the impossible. So we look to Him.

First Day

Finally, I don't feel like I'm lying in my blog header anymore! Today I spent my first day in the hospital, and I now really am a General Surgeon serving in Nepal. Although this first week or so I'm mostly just hanging out with one of the other surgeons working here...they kindly haven't put me on my own QUITE yet.

I apologize in advance if this post is too "medical" for some of you. They won't all be like this!

It was a pretty straight-forward day. Started with team handover and morning report, which happens every morning at 7:45. The interns and residents give a summary of what's happened in the hospital over the last 24 hours, so that we all have an idea of what's going on. Then we made ward rounds. I'm not sure how many patients we saw, but there was certainly a range of problems. There was a baby with burns on the leg but who can't get a skin graft until her diarrhea settles down (risk of infecting the graft). There is a woman with a badly burned right side whose skin graft isn't taking very well. They are the only 2 burn patients in the hospital right now. Apparently there were several more last week, but all the others were getting so sick that their families just took them home to die. Such is life in Nepal.

There was someone recovering from surgery for an upper GI bleed, a man with a chest tube in each side for bilateral pneumothoraces (collapsed lungs) after a fall, another man in a halo because of a C-spine injury (who is actually recovering some of his extremity movement, and has been here for 4 weeks already and hasn't developed a bedsore, thanks to good nursing care and a fancy mattress with air pockets that inflate and deflate at different times to constantly redistribute his weight), a young boy recovering from surgery for a ruptured bladder and urethra after a fall, someone else with a hip fracture in traction, a man with some kind of immunodeficiency with multiple chest wall and back abscesses, a pancreatitis, someone else being monitored for a head injury after a fall, a couple postop patients who had ureteral stones (in the tube connecting the kidney and the bladder) removed, a kid with Henoch-Schonlein Purpura with a possible hydrocele, and a bunch of other things that I can't think of right now

Oh, and there was one post-op appendectomy patient. Fairly routine for a general surgeon, but the sweet part of this story is that the 2nd-year family practice house officer (kind of like a resident) who is hoping to get into a surgical residency, was telling us the story, and beaming from ear to ear because he had done the appendectomy skin-to-skin himself (with the staff orthopedic surgeon, who was the one on call that night, just standing closeby). He had done a great job, and he was thrilled. It was neat to see how visibly excited he was. Makes me excited about the teaching component of my job here.

Before the OR starts, we have our all-important chiya (tea) break in the hospital canteen. Today I had chiya and samosas. The OR started around 10:00 or so. I basically joined another surgeon for his OR day, but we split the cases. For my first day I got a couple of easy things...removing a small mass (looks benign) off the shoulder of a 9-year-old girl, and a straightforward inguinal (groin) hernia repair. For you surgically minded out there, yes, we have prolene mesh here, and I used it and did essentially a lichtenstein repair under spinal anesthesia. For the rest of you, you don't care...sorry! Prolene mesh is pretty cheap (less than $10 for a large piece...you cut a piece out of it to get the size you want, and then the rest gets resterilized and used on the next several patients, too). We also have a good variety of suture materials...all the ones I'm used to working with at home, so that's great. Gloves without holes in them get removed, sterilized, and reused. And, of course, we have cloth drapes. There is one doctor (Nepali) who has some anaesthesia training, and another one in training at the moment, and there are nurse anaesthetic technicians. We can do both general and local/regional anaesthesia here.

The last case of the day I did together with the other surgeon. It was a bit complicated. Looked like some kind of abscess (pocket of infection) inside the abdomen, but we couldn't tell from the ultrasound what it was or where it was coming from (Yes, we have ultrasound here. No CT, of course). Turns out, in the end, we're pretty sure it was his gallbladder. It was HUGE, and full of stones and really (sorry) foul-smelling pus. And it was stuck to everything...the colon, the duodenum, the liver, etc. We worked in there for quite awhile, and eventually opted to just remove a portion of the gallbladder (the part we'd managed to free from everything else), and then stick a few drains in and quit before we did something really bad (like perforate his duodenum) while trying to do something good (like take out his gallbladder). So that one was a bit of a challenge, but at least it was very much within the realm of what I'm used to...i.e. operating inside the abdomen!

I had an intern with me, and she assisted and closed the skin at the end and did a great job. As I mentioned, I am excited about teaching here, though I will still be learning a lot at the same time. I do believe that's what I've been brought up to believe a doctor should be...both a student and a teacher at the same time. So I guess that's okay.

I was happy to discover that I have not forgotten how to operate...nor have I lost my love of surgery and medicine. I had been starting to wonder after almost 6 months of not being in the hospital how I'd feel being back, but I feel very much at home...at the same time as this is all very new and will be for quite some time.

Tansen Home

As promised, here is a tour of my home here in Tansen.

The kitchen is the first room you come to when you walk in. I spent quite a bit of time after I first arrived trying to figure out the stove. I didn't realize that you need a lighter to light it, and I was wondering why I kept turning the knob and no flame came...and why the kitchen was smelling more and more like gas! I eventually figured it out.

Next is the bathroom - my least favourite room of the house. Water shortage is a big issue here, so you do everything you can to conserve water. Thus, there is a bucket under the sink, and the water in the sink drains into it. You also stand in a bucket to shower, so that you can collect the water you use. The final common pathway? The toilet. Yes, it's true that there is no back to the toilet, and that it appears to be smack in the middle of the floor. And there is no flushing mechanism, other than pouring water down it. 

As for the shower, it took me quite awhile to figure it out. There is an electric water heater, which works when there is proper electricity (and not just generator electricity). There hasn't been proper power the last couple days, so yesterday I skipped the shower, and today I opted for a cold one. The first day, there was electricity, so I turned on the heater about 30 minutes before shower time. Then it took me a good 10 minutes to figure out which knob you turn to get the hot water, which one gets you cold water, and which one makes it come out of the shower. And then getting the balance between hot and cold was quite a challenge, so I decided I might be best off just leaving the hot and cold knobs exactly as they were and just turning off the shower. Bad idea, as it turns out. A few minutes later I could hear the sound of running water, but assumed it was the guy next door showering. About 30 minutes later, someone knocked on my door and informed that that water was pouring off my roof. He came in and promptly closed the knobs that I had left open, and that solved the problem. I guess I'll be fighting with hot/cold issues every day.I think I would like the bathroom much more if there was a shower curtain. The problem is that Nepalis don't use them. Few even have indoor showers (most shower outside at a local public tap, or they do bucket baths), and those that do have showers don't seem to mind that the entire bathroom gets wet when they use it. So despite my best efforts to find a shower curtain in the Tansen bazaar yesterday, there was none to be found. Fortunately there is a couple I know coming for a visit next week from Kathmandu, and they have kindly agreed to buy one for me and bring it along.

 I really like the living room, but I really DON'T like the "couch" at the moment. It is a bench with a really old, ratty piece of foam on it, and a ratty piece of cloth covering it. I'll be replacing both the foam and the cover, which will make it more comfortable, and more colour-coordinated.

There are two bedrooms, both quite spacious and with good amounts of storage space. Feel free to come for a visit if you're in the area!

 This is the house from the outside

 If you turn 180 degrees from where I was standing to take the outside house photo, you can see the hospital.  It won't be too far for me to go if I get called in in the middle of the night!

Phul Kumari is my wonderful house helper. Daily life takes a lot more work in a place like Nepal than it does back home. Laundry is done by hand, cooking is always from scratch, groceries are purchased daily at the market or little shops, and there are other things too that make it pretty much impossible to both work full-time and keep house. Phul Kumari works for me two days a week, and is doing a great job so far. She cooks both Nepali and some western dishes, and is lovely to have around. She also is great for practicing Nepali with.