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.