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.