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.