141. Papal Influence, part 2

And....     the hospital pharmacy will now carry drugs and devices (birth control pills and IUDs) generally prescribed for contraception but having other uses as well (e.g., alleviate abnormal uterine bleeding).

Of course the assumption is that such prescriptions will cite these other uses.  But another loophole to be sure.

140. Fast Work, Frank

Pope Francis has been in office for only a few days, but already his influence has reached the shores of the Pacific.  The local Catholic hospital is easing up its rules on elective sterilizations, a Catholic no-no (perhaps not quite the "machination of the Father of Lies" as the new Pope has characterized gay marriage, but still verboten).

Routine (i.e., no advance approval required) tubal ligations have been allowed at this institution only if performed in conjunction with a cesarean delivery.  In my limited experience, this has been the case in other Catholic hospitals run by nuns; in those under the direction of priests, no tubal ligations under any circumstances. The principle is that if the woman were to have a tubal ligation as a separate procedure in the future, that additional procedure would carry more (albeit negligible) risk to her health than by doing it at the same time as a cesarean delivery.

Now any procedure can be included under the same generalized exception: "surgical sterilizations not needing prior approval... existing medical condition requiring surgery and/or treatment modality that increases health risk should the patient become pregnant the tubal ligation becomes medically necessary [sic]."

Two loopholes here (yes, you can drive a truck through them).  First, the phrase "increases health risk" as opposed to the "risk to life" that is the usual exception to Catholic health directives.  Second, before just cesareans, now, you name it, as in, "while we're removing your ingrown toenail, would you like your tubes tied?"

139. Takeo Eight: Wrap Up

So, about a hundred cases.  Four general surgeons did mostly hernia repairs, with some partial thyroidectomies, and one mastectomy (which may or may not be curative for a large tumor present for a year and with no options of chemotherapy).  

The two gynecologists saw mostly prolapsed uteri, a combination of poor nutrition (weak ligaments), heavy work in the fields (heavy lifting), and for some many births (though the average operative patient had just two or three births, again poor nutrition's effects on fertility or perhaps many war widows).  Also, a couple of uterine fibroids, ovarian cysts and an exploratory surgery for an ectopic pregnancy based on external ultrasound, which "strongly," but in the end mistakenly suggested ectopic pregnancy. 

I did 10 cases over 5 days, which is about what I had planned for (I brought ten pre-sterilized surgical packs with drapes, gowns and "lap tapes"--think small wash cloths).  We had more than enough supplies and medications and in fact left much behind for hospital use.

The only organizational disappointment was lack of pre-screening, which put us behind a day, but not more than that.  On other trips lack of pre-screening has had a much more negative impact. Within the surgical team, many working together for the first time, communication among the staff couldn't have been better; I'd work again with any of them, docs or nurses, anytime, anywhere.

Finally, we used almost no narcotics for postop pain.  Other missions have had limited amounts of narcotics.  We just provided ibuprofen and.... ice.  Families would go out and buy block of ice which would be wrapped and placed on the patient's abdomen. Just based on my visual observations, I don't think these patients experienced any more pain that what I see with patients who have immediate access to various narcotics.

138. Takeo Seven: Pride

Given that Americans have made such incredible blunders under the banner of pride, let's give some slack to our hosts.  Often unwilling hosts.  Sure, local political and ecclesiastical leaders may ask us to come (well, maybe better said responded favorably to our requests to come), and perhaps hospital administrators as well, but the front line staff seem less eager to see us. Some may view us as adding to their already busy, poorly paid days.  More rooms to clean, instruments to sterilize, crowds to handle.  

And medical staff: do they ask our opinions on difficult cases, request lectures, or ask to watch surgery, to learn new techniques?  By and large, nope. At the end of the week, we heard (warning: second hand info here) that in a new wing of the hospital, there were new and better equipped operating rooms. That's okay, why should they suspend their schedules to give us free rein? The staff doctors didn't even know we were coming, the hospital administrators curiously keeping that to themselves.  Or maybe they did know, but said they didn't to justify their wariness.

And then there's Halothane.  Since Queen Victoria used ether during childbirth, anesthetic gasses have come a long way. Introduced in the 1950s, Halothane is cheap and has a positive side effect as a bronchodilator (relaxes airway muscles), but because it's slower (slower to sleep, slower to wake up), and because of rare cardiac complications, it is not even available in U.S. Cambodia, on the other hand prohibits the use of any anesthetic agent other than Halothane. This could be a pride issue--rather than admit it can't afford the other agents, the latter are simply outlawed--or it could be a reasonable attempt at cost control. Maybe something we could learn from. Darn it, there's that pride thing again.

137. Takeo Six: For Me?

Left: student Botha; Right: team RN

As happened in Mozambique (there fortuitious, here planned well in advance), medical students served as translators. I think they learned a lot, their studies not having yet exposed them to patients. I was explaining preeclampsia to one and drew some diagrams. Finished, I handed him the drawings; he looked surprised and asked, "For me?"

Three medical schools, two private schools teaching in English and the French-speaking government school, serve Cambodia's 14.8 million population. Private school tuition $1000 per year, going up to $2500 next year, they tell us. Combined, the three schools graduate about 150 new doctors per year every year, so one per 99,000. Compare that with America's yearly class of over 17,000, or one new doctor per 18,000.

Medical economists don't think that's enough to replace physicians who are retiring earlier than predicted, or who have cut back their hours. 

That retiring issue--not so much a problem in Cambodia, since many (most?) of retiring age physicians did not survive the Khmer Rouge brutality.

136. Takeo Five: Local Support

We try to bring our own supplies, personnel and meds, but are still rely on local facilities for OR rooms postop beds, and night nurses (I haven't seen any teams bring their own nurses for care of postop patients at night).

This hospital had the best night nurses I have worked with: reliable, knowledgeable, and good at documenting their care. The ORs have relatively new anesthesia machines (which means ability to monitor heart rate, oxygenation, and flow of anesthesia gasses). Overall, better facilities and support than I have seen elsewhere.

Interesting bed, you're thinking, but where's the mattress?  See the straw mat--that's it. And note the stacked porcelin dishes under the bed--families bring food.  Finally, the red pail? A chamber pot.  Yes, a chamber pot; patients stand up and pee at the side of the beds, which are of course in open wards. There is a squat toilet down the hall, but for postop patients not yet able to walk that far, if they can just stand at the side of the bed, they use the pot. When you think about it, not that much different from the bed side commode we use in the States.  Sit or squat, behind a curtain, or not, it's all relative.

135. Takeo Four: In the Spotlight

Two scrub assists, each ready to go

Yesterday we had two tables set up in the same room (a common practice for overseas teams); it's a large room and although sometimes a bit noisy and hectic, works out.  Infection control freaks will object but for the low risk (infection-wise) procedures that we are doing, this is not a deal-breaker.

The room has just one overhead spotlight, but otherwise well lit, and I have my head spotlight--an item researched and bought for me by my son.  Similar spotlights are found from Costco to REI, for night bikers, hikers or campers, but adaptable to the OR, though my light has the advantage of being more focussed. So I didn't mind the overhead light being used by the other table. I was overoptimistic: the first case (see yesterday), didn't have the best lighting and I initially thought just wasn't up to the task at hand.

Then a "duh" moment.  My batteries! Almost dead. So I waited for the other table to finish (just a few minutes) and had the overhead light moved over.

Later I replaced the batteries and noted that the dead batteries were the original, now a couple of years old; with new batteries I had all the light I needed.

Lesson: start trips with new batteries or newly charged batteries in spotlights, cameras, whatever.