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!