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.