250. Nepal--final post

Last round of pix from Nepal mission: two from recovery, one from postop rounds; tattoo on preop pt.

Ciao

249. Nepal Day 16

Wednesday Morning 3 AM.  Actually it's Thursday and 4 AM; I'm awake as usual (never really accommodated to time changes); can't turn on light with roommate asleep and nowhere else to go (the strip motel we're staying in has no lobby to speak of). 

Staring at the ceiling, I'm thinking what am I going to do the next two days until the group packs up and returns to Kathmandu? With no gyn surgery scheduled and just a handful of postop patients for six gynecologists to round on, not much to do.  I know because yesterday there was just one surgery; spent a lot of time wandering the halls.

Well, what about returning to Kathmandu early (where my wife has been hanging out, sampling the Buddhist culture? I'd have to arrange a car to the airport (90+ min away); once there change my flight; then grab a cab from KTM to her hotel.  Everything falls into place, including dropping off an older laptop (that I use for travel and don't really need anymore) to a school that I pass by every morning (these three pics are all from this school with its open air, crowded classrooms).

Problem is that though I try to let people know and say nice goodbyes, I don't actually ask permission and thereby engender some significant ill will.  I have a good time with the extra days in Kathmandu but all things considered, probably should have stayed.

248: Nepal Day 15

Another postop patient returns, dehydrated with watery diarrhea.  She responds well to intravenous fluid hydration but we do worry about clostridium (see day 12 post).  Or it could be cholera which is endemic in Nepal (Nepalese soldiers transmitted cholera to Haiti)? Or non-clostridium bacteria taking advantage of the elimination of normal (”good”) bacteria by preop or postop antibiotics? Or just a common viral or bacterial gastroenteritis, the same thing that's been affecting members of our group? We encourage extra hydration, which once home may mean more unsafe water than the usual safe tea. Then two more patients arrive, also with gastroenteritis. All did well with fluid hydration.

Performed my final vaginal hysterectomy today; we decided not to do any gynecologic surgery on Thursday or Friday given the number of re-admissions and our departure set for Saturday morning. General surgery continues to do simpler procedures such as hernia repairs and hemorrhoid banding, both less likely to have the kind of postop complications that we have been seeing.  They and the dentists will all stop work noon Friday.

solar "suitcase" closed

solar "suitcase" open
showing converter and battery

The mission is more than just surgery. We brought 100 pounds of prosthetic hands and “solar suitcases,” which includes a solar panel hooked to battery for two LED lights for an operating room when the power fails. One was installed in the hospital last year and another couple were placed in villages a few hours drive away.

solar powered LED ceiling light 

And there is a team from another organization that provides water filters. We help provide logistical support.

247. Nepal Day 14

Difficult day on the postop ward. One young patient with a simple tightening of the posterior vagina (the vaginal floor) reported postoperative abdominal pain, back pain and and/or headache. No vaginal pain was reported. All of my previous U.S. patients with this procedure go home after a few hours, many reporting report zero pain.  

Concerned about a “white” vaginal discharge she was reassured, with the caution that a vaginal discharge becomes a concern only if associated with pain or itching or malodor. Yes she promptly reported, she was experiencing all three. But an exam showed only a slight blood-tinged discharge that one would expect in this postop setting. 

Nepalese nurses and doctors spent much time with her, eventually discovering that she hadn't taken thyroid medications for four days—but it turned out that it was such a low dose that even four days missed should not elicit the symptoms she reported immediately postop. Questionable use of thyroid supplements for fatigue and weight gain among other complaints has a long history in the U.S., and it would be not unexpected to find the similar prescription patterns here. She ended up staying three days.

"They all want medications" I was told by a local nurse using “antibiotics” as the generic term for any pharmacologic cure. But then again, so do I with my tumeric, vitamin D ibuprofen for arthritis, along with thyroid and HCTZ, which is another story (osteodude.blogspot.com).

246: Nepal Day 13

Still doing 30-45 minute vaginal hysterectomies (in the pic I'm the primary surgeon) then assisting complicated 1-2 hour vaginal suspensions for the same patient—bent over, holding a retracter, no opportunity to stretch or change position, operating room at least 75-80 degrees—inside my impermeable gown probably 80-85. Plus my headlight is pressing into my forehead—okay for a few hours but after that it just adds to the general discomfort. Not what I signed up for I think until it's over and I can take the headlamp off (as an assist, I don't really need it but it would be awkward to remove it during the transition from primary to assistant surgeon).

Walking home, a guy came up and initiated a conversation.  He first encouraged us to change sides of the street, walking on the left following
English-pattern driving (I didn't point out the safety of walking facing oncoming traffic). He's a math teacher with a son who wants to be a doctor because doctors earn more than the $200/month teacher's salary of his father, which “isn't enough to live on” (current minimal monthly income is $92)). The son wants to study medicine in India, which offers medical school scholarships to Nepalese students. (I met one of the recipients of these scholarships who is spending a government-required two years practice in Lahan before returning to Kathmandu). He also commenting on the tug of war between China and India over Nepal.  City people, he said, usually have Indian connections but “hill people” favor China.

245. Nepal Day 12

Surgery today uneventful, but in the evening a patient from the first day returned after not feeling well for several days. Low blood pressure, no significant urine output, rapid heart rate, and rapid respiratory rate. No fever. Appeared in considerable distress.

Severe dehydration? Internal bleeding? Septic shock (systemic infection; see post #)?  

A "stock" image showing healthy pink bowel
and necotic dark bowel segment

Deteriorating vitals signs prompted surgery which showed a necrotic bowel. The necrotic areas of the bowel were removed, and the patient transported to the nearest hospital with an ICU, about two hours away, where several hours later she was reported as stable. 

Which came first, an infected bowel (say from accidental surgical injury) or necrosis from inadequate blood supply which then led to infection? The surgeons “ran the bowel” (that is, inspected the bowel from top to bottom) and found no evidence of perforation.  

Regarding the latter, at her age (71 it appears now though in the clinic she said she was 60, perhaps translation error or concern that she would be rejected because of age), there could be poor bowel vascularity—not enough blood going to bowels means not enough oxygen which increases risk of tissue death and widespread necrosis.

A final possibility is the antibiotic that a Nepalese doctor gave her at discharge (we would not routinely give antibiotics for a postop patient).  A not uncommon bowel bacteria call
clostridium is not covered by these drugs and could take advantage of the open field provided as normal bacteria were eliminated by the antibiotics. But clostridium infection
is usually associated with severe diarrhea. 

Lesson learned? Better attempts at screening for age or age-related conditions--easer said than done. Longer post-op stays: 2-3 nights after surgery instead of 1-2. Low threshold for use of metronidazole, the one antibiotic that covers clostridium. And a tweak of the method used to clean the vaginal wall.

244. Nepal Day 11

Back to work today. Concluding that during the previous week too many cases went too far into the evening, the decision was made to cut back surgeries: 4 operating room tables instead of 5.  

An anesthesiologist from Kathmandu helped today and hearing our stories of unexpected blood loss said that in his practice the expectation is that almost all hysterectomies will have sufficient blood loss to require transfusion.  We think maybe some dietary deficiency--some missing mineral vital to the blood clotting mechanism.  Dietary yes, but not deficiency.  Garlic, for example, is an anticoagulant, perhaps ginger as well, both common ingredients in local cooking.

Several providers ill with gastroenteritis.  I estimate that with each mission, 10-15% of participants at some point become incapacitated, though usually for just 1-2 days. Rest, fluids (sometimes intravenous), and antibiotics for travelers' gastroenteritis usually are sufficient.  I'm lucky, I remember just one afternoon in Malawi, when I returned to my room, just feeling poorly, perhaps lingering jet lag/sleep deprivaton, since I felt better after several hours sleep).  True GI illness did get me a couple of times, but on the way home so didn't disruption mission activities.

243. Nepal Day 10

Sacred cow wandering on main street

Day off (Saturday is the traditional day off in Nepal); some of us went to a wildlife sanctuary, by chance sitting in the bus ( a 90 minute ride) next to a nurse who shared “office politics” with me—the mission's chosen (but in situ unqualified) lead OR nurse picked because she was office nurse for the lead surgeon. After a verbal duel with a "take charge" nurse, the former ceded her position to the latter. My confidant works at the same hospital as the original lead nurse, with grievances that appear to predate the mission by some time. I was oblivious to all this until the bus ride, and never noticed any dysfunctional relationships (to which I also could have been oblivious). 

The ride took us within a few miles of the border with India, a reminder that Nepal is 80% hindi, probably more in the east.  India is known for it's skin-whitening creams. This picture of a woman about to receive a spinal anesthesia provides a partial explanation. Traditional clothing (sari) exposes her lower back as she bends over planting/harvesting rice, thus the deep pigmentation. Darker skin = common laborer.

242. Nepal Day 9

Without the pressure of a fee-for-service or a strong continuity of care theme give the see-one-day, operate-the-next, and home-the third (or fourth), the lead gynecologists scheduled patients without feeling this need to have the doctor who made the initial recommendation actually do the surgery. 

The concern is what if I am scheduled to operate when if I had first seen the pt I would have chosen a different procedure or non-surgical management. 

And that's what happened. While I was finishing rounds, I patient I had scheduled for a vaginal hysterectomy was instead prepared for an abdominal approach, based on    findings from an exam under anesthesia, an admittedly more informative exam. Scarring was suggested which would make the vaginal approach at risk for significant complications. However, an abdominal has a higher risk of complications and certainly a longer recovery. No scarring was found and the patient experienced more bleeding. 
But who knows, even more bleeding may have occurred with the exposure-challenged vaginal procedure. At some point, you take your colleagues' decisions at face value, stop the second-guessing, and move on.

241. Nepal Day 8

More of the same: vaginal hysterectomies followed by vaginal suspension or closure

Our hotel is two miles up the road—the country's main highway, dusty with cars, busses, motorcycles, bicycles, and lots of trucks, all weaving in and out with constant horns. Most motorcyclists wear helmets but their passengers don't. Cyclists have no helmets and no lights, which is tricky at night. Some of us walk the four miles daily; others take the three-wheeled electric taxis that seat a tight four--”tuk-tuks” in other countries.

The nurses work the hardest, arriving early to prepare instruments, rooms, and patients for surgery; many stay until the last patient has made it though recovery and to the ward.  Local nurses are hired to take care of patients at night.  

No elevators so a long ramp allows gurneys access to the second floor postop ward.

240. Nepal Day 7 part 2

Three cases today:
1. 60 year old with complete uterine prolapse (the ligaments that suspend the uterus are so stretched that the uterus has fallen first into and then outside the vagina. During surgery the small atrophic uterus is removed (my part) and then the gyn urologist does her part, elevating the vagina and tying it to a ligament near the spine .  A tedious procedure (because many sutures are required in hard-to-see spaces) for the the surgeon and for the assistant as well (that be me).

2. 38 year old with a weak rectal-vaginal septum (wall) that protrudes into the vagina and interferes with normal bowel function. Like a seamstress's dart, skin is brought together and redundant tissue removed.

3. 65 year old also with complete prolapse but in this non-sexually active (and never expecting to be) woman, removal of the uterus then closure of the vaginal opening is the safest route.  First the surface skin layer is removed from the vaginal ceiling and the vaginal floor. These exposed areas brought together with suture.  When healed they will form a strong wall that essentially closes the vaginal opening.

One would think that complete prolapse would make for easy hysterectomies since the primary target of the procedure--the uterus--is right there, easy to see and manipulate. But not so; the descent distorts normal anatomy (so blood vessels and other structures are not exactly where you think they should be). And the many year exposure to the outside environment toughens and thickens the vaginal skin.  Compare the peeling of a naval orange (normal anatomy) to a juice orange.

239. Nepal Day 7 part one

First surgery today. We have two operating rooms, one with an single overhead light (doesn't make much difference; we all have headlights—some from Costco or REI, others medical grade and several hundred dollars; you get what you pay for), two operating tables and working air conditioning.  The other room has no overhead light, no air conditioner, and three operating tables. That's the room I'm in, center table with patient receiving spinal anesthesia.


Other missions have also used a single OR for two simultaneous operations (which makes it easier to share personnel and equipment) but this will be the first hat trick OR. 



Our “dress code” may raise eyebrows but the sterile integrity of the OR hasn't been breached tho the personnel (in this case an anesthesiologist) may not be as protected against spills and falling objects.