Scalpel's Edge

A surgeon's notes

Fun Friday

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Time is rushing past.  It’s easier to write updates when I am studying language and have extra study time on my hands.  Writing is much more appealing than flashcards!

I have been back at work about a month now and even had a holiday when my sister came to visit. The weather has cooled down and we took the opportunity to do some bushwalking, or trekking in the Annapurna range and near Tansen.  We were surprised how much the children enjoyed their walk.  I’m not sure why it is so terribly difficult to walk five minutes to a friends house, but exciting and adventurous to walk two hours up a steep incline.

Friday was a snapshot of life in Tansen.  It is fascinating and surprising and troubling and fun.

We started with our ward round as always and yesterday we were concerned that our skin grafts are failing more than they should.  Because of location (away from Kathmandu) and the fact we aren’t a profit organisation (and people can afford to stay in hospital for the time that treatment requires), we are one of the major providers of burn care in Nepal.  We have 12 dedicated burns beds, which are not all full at the moment, but in cold weather (when people spend more time near fires) burn cases spill into the rest of the hospital.  Anyway, skin grafts are a major component of surgical care in replacing skin that has been burnt away.  A thin slice of skin is shaved from an unaffected area and sewn onto the burnt area.  After a five days we takeoff the dressings and see whether it has healed.  It’s devastating to find out that none of the skin has stuck done, or there is an infection in the graft.  Commonly they don’t stick or take because they have been infected, or the skin (usually shaved from an unaffected thigh) is of poor quality.

We are not sure why we are having trouble.  We are going to give our burns wards and our surgical equipment an extra deep clean.  We have stopped used our mesher, which fenestrates the skin to help it stretch and bond better, because we think it is crushing the skin.  It has multiple blades and most likely these are getting blunt.  At home we would get the machine refurbished or replaced, but that’s a major deal here, with no budget and in a remote part of Nepal.  We have our thinking caps on, but in the meantime, we are without a key piece of equipment.

After discussing this problem for a while and coming up with some strategies (and having tea), we started the operating day.

I started with a straightforward groin hernia.  This is a bread and butter case, and an operation where I feel in control. One of the junior doctors came in to assist me and finished the case.   He is still at the stage of having to concentrate really hard for this and his stress reminded me of one of my surgical mentors talking me through a hernia repair, more than ten years ago.  I concentrated on being as patient as she was then.

We next did a laparoscopic cholecystectomy on an 11 year old with a gallbladder empyema.  I’m not even sure how a kid that age gets such bad gallstones, but Nepali kids are pretty small, so I felt like I was using two metre chopsticks. My next case was a 91 year old man who needed a mastectomy for breast cancer.  It seems the only cancer patients I treat here would have been outliers in Melbourne.  An acute scrotal exploration for possible torsion testis (an emergency where the testis has it’s blood supply cut off and may need to be removed) was followed by a straightforward laparoscopic cholecystectomy, which my GP surgeon colleague was able to do.

Although I only got back from holiday last week, I felt exhausted by the end of the day.  Part of the stress for me is the fact that our days are so different from each other.  It is not uncommon to be doing a case I haven’t done for a while, and have to revise what suture and technique I will use. When cases are straightforward, I try to teach someone else how to do it, which is a different type of concentration.  This variety is the joy and pleasure of general surgery, even more so here in a “real” generalist environment.  But at the end of the day, the tiredness is real.

Friday was capped off by a doctors party to farewell some of our residents who are leaving. Doctors parties in tansen are like birthday parties – kids games like celebrity head, team dictionary, trivia and musical chairs, followed by pizza and soft drink.  Remember how fun those parties were?  That’s the perfect antidote to a busy, and confusing and challenging day.

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