I recently had the opportunity to meet one of my early surgical mentors.  He guessed that we had worked together a decade ago, where it was in reality much closer to two decades.  He was genuinely surprised by this.  I don’t know if his protests were rooted more in his own self-perception, or my youthful appearance, but I will take it as a compliment.

Already an experienced surgeon when I first met him, I felt the contrast between his “old school” experience and my own “younger fellow” idealism.  Surgery has seen vast developments, even in the last twenty years, let alone a full surgical career.  Thirty years ago, gastric suppression drugs, such as proton pump inhibitors, were unheard of, and the role of Helicobacter was not understood.  Complicated ulcer disease was a very common hospital presentation, and in the absence of flexible endoscopy, surgery was one of the few treatments.  In fact, my colleague told me that one of their ward treatments for gastric bleeding was nasogastric installation of ice water to promote vasospasm.

Our expectations of competency in general surgery are based on a recent memory of these diseases.  Every surgeon should be able to deal with a bleeding ulcer, and do a gastric resection if required.  While that was undoubtedly necessary thirty years ago, it is a much smaller part of our practice now.  I had not operated on a patient with bleeding ulcer until I was finished my training.  This is not unusual –   these diseases are simply not that common.  

There are other examples of change.  The advent of ERCP and laparoscopic cholecystectomy together have led to less open bile duct explorations, and surgical trainees who have no experience in operating on and repairing the bile ducts.  In fact, many are more scared of the bile duct than a major blood vessel. General surgeons less commonly operate on skin lesions, so we are much less experienced at local reconstruction.  Open abdominal surgery is less common, so we have to develop the dual skills of open and laparoscopic mobilisation of the bowel.  Splenectomy is rare due to improved passive safety and seatbelts, and splenic trauma is increasingly treated with embolisation and in trauma centres.  As a result, many young general surgeons haven’t removed many bleeding spleens (in Australia, at least).

So, if surgical practice changes drastically in the space of a career, we probably need to adjust our expectations of skill minimums in graduating trainees.  However, the most senior generation of surgeons tends to be the group that dictates training standards.  Although natural, the expectation is that trainees to know what they need to know now, AND what they would have needed to know thirty years ago. 

As educators, I dream that we are all professional enough to take these biases into account, and generously accept that new trainees will need a different spread of competence than senior surgeons. Pragmatically, I think we will judge them for being under skilled and experience poor, and continuously sabotage their confidence and training time.

(As an aside, I think it is a bit absurd that I am genuinely a younger fellow at 43 years old.  Educational constructs that create this sort of contrast do a lot of devalue our trainees, who at 30 and 35 may not have even achieved “Younger Surgeon” status in their own mind.)

Image used with permission “Behind Closed Doors”

Absence is the enemy of love – Traditional proverb

It seems I just turn around, and my previous life has dissolved.  This confessional blog lies dormant, and my life here in Bendigo is now established.  However, the return to first world medicine has not stopped me questioning and discussing, examining and exposing my experiences as a surgeon.  

I have been amazed by the differences in medicine and surgery in this place. Where Nepal felt frantic and desperate, Australia feels strident, and competitive and defensive.  There is no value here on efficiency with equipment or consumables, on reducing waste and expense.  But there is a huge value on outcomes, at whatever cost.  There is a general assumption that every patient wants the same thing – the highest possible standard of invasive care, so much so that the withdrawal of that care, or any problem or stutter is a major event, requiring either extra compassion, or extra explanation.

With that level of care comes extra possibilities, though.  Many options for nutrition.  Cool devices.  Extra support and a choice of skilled assistants and anaesthetists.  Equally, more fear – fear of failure, fear of mistakes, and fear of being unable to justify your mistakes.  And perhaps also lack of appreciation – we do so much, achieve so much, and focus much more on the stumbles than the success stories.

I hope to return to discuss, dissect and revel in these surgical conflicts, and with your permission, I hope to share them with you.

There’s no doubt that living in a foreign culture has been an amazing experience for my children, but it comes with challenges as well.

My kids can’t wait to return to Australia because they remember – a bath in more than a bucket, drinking water directly from the tap, more than one bathroom in the house, glazed doughnuts, and MacDonalds hamburgers.  However, I can also imagine the things they have forgotten – carpet, and central heating, warm water from any tap.  There must be a thousand things that they have forgotten about Australia in two years, things that won’t seem strange to Luke and I, but which might be exciting discoveries for the kids.

Mission literature (which I never knew existed) talks about “third culture kids”.  This is the concept that kids that grow up in missions end up with a mixed culture.  In our example, they are not Nepali, but they are also not fully Australian.  They are, to some degree, outsiders in both worlds.  They live for this time in a third culture – that of the expatriate. I think this holds true to a degree, and I can imagine even more so for longer term missionaries.  

My kids know Nepali kids and can be polite to them, and, to a degree, culturally appropriate.  But they will always be the foreigners – often photographed against their wishes, and mobbed by nepalis in a crowd.  And I imagine when they return to Australia, they will not automatically fit in.  They will be the kids who went to a tiny composite school, and who eat weird food, and talk frankly about patients who die, and know what poverty looks like.  On balance, though, after just two years overseas, I imagine my children will return to feeling at home in Australia, even if it takes them some time.

I know people here whose children grew up for most of their childhoods in Nepal and I  have heard them talk about the loss of homeland.  These kids have no “where I grew up”.  I know friends whose children have returned to “their” country with only memories of Nepal, and the struggle to deal with the foreignness of “home”.

It occurred to me recently that maybe mission adults live like this, too.  We had friends visit this week who once lived here for two and a half years. I get the impression that they are no longer fully american.  They feel comfortable in their home country, but at least part of their home is still here.  

As we prepare to leave, it becomes clear that leaving is more complicated than arriving.  My husbands plans change regularly, but he feels he will always be tied to this country and town.  His wishes and dreams are more here than at home, at least for now.  My surgical heart is wearied by working in this foreign place, and I need to return for a breath of familiarity.  But I recognize now that surgery in Australia will be anticlimax, and maybe loss. My initial excitement when I arrived in Nepal about grass roots diagnosis and treatment will be balanced on my return.

There is no doubt that I miss Australia, and it will be a relief to read cultural cues without stumbling.  However, I can’t ignore what I see on the face of all those who return to visit.  The memory, the homecoming, and the inner fracture.  Living overseas, even in a crazily foreign culture, is different to visiting.

If we have a signal inside our heart that always points home, what does it mean, when your signal points to two different places, even if just a little?

Grandmother wise

In Nepal it is getting colder.  Winter here is sunny in the day, warm enough in the sun to dry clothes, but icy cold overnight. Now it is Autumn, for want of a better word, and the nights have become colder.  Many village houses have open windows for ventilation, and people rely on being close to a fire for warmth.  Imagine how you would be in a house with no electricity, and no fireplace, living in the icy cold.

Grandmother Wise came to us with flame burns along the both sides of her legs, over her perineum, and across both the front and back of her trunk.  She had been standing with her back to the fire, warming her legs.  Many older women in this region  wear saris – loose flowing garments wrapped multiple times around the body, made of cotton or silk.  If you have your back to a fire and your sari catches fire, I imagine you don’t immediately realize.  There is time for the fire to flicker and strengthen before you feel the burn.  And, as I know from surgical outpatients, it takes a long time and effort to put on or off a sari – most ladies insist on examination around, under and through.  

This pattern of burn is quite common over winter in our hospital.  We often have three or four by the end of winter.  When I look after them, I can’t help imagining the frail grandmothers, struggling in fear to remove a garment that is burning them.

There is an index in burn care that describes the risk of mortality as a function of both age and percentage of burned body surface.  This means that the older a patient is, the less likely they are to survive.  Tertiary burn units achieve higher survival, but in our world, likelihood of survival is 100% minus the sum of age and percentage of burn.  

Many of our patients with this burn pattern end up with around 20% burns – deep burns to the back of both legs and perineum (the area around the bottom and genitalia) and usually both hands.  They are penalized by their age and stay much longer than we hope in hospital.  Many give up and hibernate under blankets, seeming to hope that death will take them.  Often it does.  They may even survive for a few weeks or a month, only to succumb to pneumonia, or something as simple as a urine infection.  We had one patient who hibernated for a month before realising her burns, at 12%, were not severe enough to kill her.  She came close, but was discharged to our cheers.

Our Grandmother Wise had 65% burns and was over 65 herself.  My resident when he described her spoke uncertainly – no one wants to say the high percentages out loud.  It is as if, by saying it, we give the burn more power. We knew she couldn’t survive.  She died fairly quickly, within a day.  Her family were with her, and we did our best to save her from pain.  But she never went home again to the place she had lived.

Strong young man

On one of the biggest religious festival days in the Hindu calendar, the Strong Young Man chose to end his own life.  He poured petrol over his head and body and lit himself on fire.  This is not an uncommon way to attempt suicide in Nepal, along with other violent means like hanging, and sometimes cutting one’s own throat.  Poisioning is also common, with organophosphide fertilizer ingestion being a common method.  Usually in these cases, there are social stresses often mixed with alcohol.  Mental illness is badly treated in Nepal, particularly diseases like depression not marked by bizarre behaviour and psychosis.  I mean, they don’t have enough surgeons to provide adequate surgical care. Mental health care is struggling more.  However, alcoholism is rife, and I suspect many are self medicating, like they did in Australia fifty or sixty years ago.

Given the timing, I couldn’t help think of Christmas Day at home, when everyone wants to leave hospital except for the isolated and lonely.  Our Strong Young Man burnt his head, his chest and trunk and both upper arms.  He also had burns on part of his legs.  He was in pain and his body was struggling.

Self-inflicted petrol burns are brutal.  They are usually very hot fires, causing severe injury.  If the person has enough petrol, they are extensive.  And they affect areas of the body that scar in a very public way.  Anterior neck burns are very common, and when they heal are very prone to contractures – bands of scar tissue that bend the neck forward, making the person look perpetually cowed.  I often worry about our self-inflicted burns patients.  Their burns keep them in hospital such a long time, that the treatment of the depression or alcoholism or whatever underlying cause becomes secondary.  By the time they are discharged they are scarred, marked forever as a burns victim, and are much less a person who attempted suicide.  Many seem much less depressed, more determined, as if to say, they may have wanted to die, but they didn’t want this. 

Our Strong Young Man was not strong enough.  We gave him compassion, and analgesia.  We worked hard to keep his kidneys working and his thirst at bay.  But he did not survive.  In medical euphemism we often talk about a patient’s “will to live.”  I have no doubt that it requires strength and bravery to bathe in petrol and then light a match, but it must also take a desperate will not to live.

Bonnie Babe

The baby was just seven months old, but had crawled into the cooking fire, and burnt both legs badly.  These cases are not exceeding rare. For an Australian, the accident seems unbelievable, but here, there are open cooking fires in many houses, very close to the living areas.  Can I remember a time ever when I fell asleep or was distracted and my baby ended up somewhere I didn’t expect them to be? Yes.  But in Australia that place is much less likely to be an open fire.

Bonny Babe had been admitted to a secondary hospital and had been discharged with antiseptic dressings and minimal pain relief, which is pretty typical.  For babies, outpatient management of pain is quite difficult.  Not coping at home, the family brought him to us to look after.

We discussed his injuries for some time – deep full thickness burns extending above both knees.  On the left the skin was lost almost to the hip crease.  We finally agreed with each other that amputation would be required and he had bilateral above knee amputations.  He also lost almost all the skin above the knee on the left, his stump just muscle.  While in hospital, his family fought and battled.  They blamed the mother, for her carelessness.  They couldn’t find a way to support each other.

He was with us for more than a month, maybe two months.  Although feeding and eating, and not complicated by stump infection, he ran out of steam.  Babe developed a pneumonia, and the staff held their breath with him.  In HDU he was given the best care we have – oxygen, ventilatory support, super-antibiotics, and prayers.  I lay in bed at night, hearing the medical air system decompressing in whooshing bursts, and imagined him breathing, breathing.  But he stopped breathing in the end, and was gone.

The world isn’t split into good people and Death Eaters.  We all have got both light and dark inside us.  What matters is the power we choose to act on.  That’s who we really are.

Sirius Black (care of JK Rowling)

I have an unnatural relationship with the Harry Potter series of books (and movies).  Despite an aversion to reading “the next cool thing,” I read this series from the beginning.  I distinctly remember being on call surgical registrar at Monash Medical Centre one weekend when Harry Potter and the Goblet of Fire was released.  I took the book and read it curled up on the couch in the residents quarters between calls, desperately grateful that I had a quiet weekend.  I currently reread the series about once every eighteen months or so, either the audiobook version or on my kindle.  I am currently reading the stories to my kids each evening before bed.

As I reflect on my time here in Tansen, I have been asking what it means to be here as a missionary, as opposed to any other sort of volunteer. People come to Nepal all the time to work with the poor, and not all of them in a mission context.

I suspect there are more long term volunteers who are representing a faith, because of the community of support they can access.  On a simple level, our long term missionaries are usually sponsored financially by their church and Christian friends who donate money to pay for their needs, and pray, and give other support (like car parcels).  Equally, I think that is why Tansen Hospital has such a long history in Nepal (greater than sixty years).  Providing free and subsidized health care for the very poor is not a good business proposition and the financial support, volunteer personnel and donations that go with Christian mission subsidies that longevity.  There is no discounting the support that can be created by one or ten thousand people acting together to support an organization, and by extension, a group of people.

Beyond the organisational level, it makes a difference to me to be here as a missionary rather than a secular volunteer.  Firstly, I imagine as a secular volunteers, we would have focussed more when our accountant was telling us that wasting our savings on service was foolish. Second, my heart is different.  My personal version of mission is based around the greatest commandment:

He replied, “You must love the Lord your God with all your heart, with all your being, and with all your mind. This is the first and greatest commandment. And the second is like it: You must love your neighbor as you love yourself. All the Law and the Prophets depend on these two commands.”

Matthew 22: 37-40

That is to say, I am much more passionate about service to the poor than teaching Christianity or theology.  I never wanted to be a Biblical scholar.  I feel uncomfortable talking about my beliefs with people I don’t know well.  I mean, I feel uncomfortable talking about the weather with people I don’t know well, so it’s not really surprising.  But I can love people, and I can be really good at that.  And my version of Christianity and mission basically boils down to a question – not what would Jesus do, but what can I do to love this person or that population?  What would I do right now if I loved the poor with all my heart?  What choices would I make if I loved my neighbor every day?  How do I act so that the people around me can just assume I love them, in the same way my kids do, even when they are pouring water all over the bathroom floor? 

At the moment in my work, that means caring for patients as best I can.  It means sharing my “lucky country” education with my colleagues, so they can look after the poor of this country for the next twenty or forty years.  Could I do that stuff in Australia? Absolutely.  I can teach and practice surgery, and even get paid for it.  So that leads to one of those self discussions – why Nepal?  Why not just stay in Australia?

I don’t believe that you have to be a volunteer to serve people in medicine.  I don’t believe that you have to work in the third world to serve. But for me, that is where I feel I can make the most difference, right now.  There’s undoubtedly a different need for surgical services in the third world, and a particular need in Nepal.  My skills as a fairly non-specialized general surgeon, very well trained, are worth heaps more here than in Australia.  And for the moment, that is why I work here.  

When I talk in Christian jargon, I describe that decision and logic by saying “I feel called to be here”, or that “I am meant to be here.” Those sort of phrases are a combination of truth and short hand, which makes me feel uncomfortable using them in secular discussion.  Jargon can help difficult explanations, but those phrases also have echoes of fatalism and destiny that don’t fit with my perception of mission and christianity. Christianity, in my experience is all about choice.

And this is where the Harry Potter series of books help me understand and discuss mission.  There is an overlying theme in the Harry Potter series about choice – the difference between good and bad intentions and behaviour.  This same theme is discussed in multiple literature and pop culture sources – good vs evil and the role of destiny vs choice, but we’re focussed on Harry Potter here, so let’s ignore Star Wars, The Lord of the Rings and others for a moment.

There’s a pivotal scene in the second last book, Harry Potter and the Half Blood Prince, where Harry discusses the fact that he wants to kill the evil bad guy (Voldemort) and he thinks he is destined to do it, by a prophecy made before his birth.  Through discussion, he understands that events in his life have made him want desperately to fulfill the prophecy (of killing the bad guy), but it is still his choice. The key part of this for me is, in his position, with his history, there is no other logical choice.

It was, he thought, the difference between being dragged into the arena to face a battle to the death, and waking into the arena with your head held high.  Some people, perhaps, would say there was little to choose between the two ways, but Dumbledore knew – and so do I, thought Harry, with a rush of fierce pride, and so did my parents – that the was all the difference in the world.

Harry Potter, via JK Rowling, Harry Potter and the Half Blood Prince

One way a Christian missionary can be completely derailed is by focussing on the work they are doing and ignoring the reason they are doing it.  Great work is done, but without a focus on God.  For me, if I were to be here, doing the same thing, but without tying it to my central spiritual belief, it would not be at all the same.  From working with God, we suddenly get access to a whole load of support of others all over the world who care about us and this hospital and their prayers.  And we also get a touchstone.  A reason and a choice.  But being Luke and I, and having the experiences in life that we have had, this is the only place we can logically choose to work.  And that is what I mean by calling.

Anything is possible, if you’ve got enough nerve. 

Ginny Weasley

Whenever I travel by car, I find myself smiling.  The nepali road trip is speed-limited by poor roads, and road rules which gives fault always to the person behind.  This means that everyone travels a bit more slowly, and although it doesn’t seem more careful, obstacles can float across the road relatively safely.  It’s an excellent way to view the day to day life of Nepal.

I should note that while I live in the mid-hills, where there are very few bicycles, this trip I was traveling in the Terai (the flat plain in the south of Nepal) so bicycle traffic was ubiquitous.

On this trip, I saw typical activities that I always see on the roadside, and some things I have never seen before.

• people washing their dishes in a tap on the side of the road

• alcohol for sale alongside salty chips

• people washing themselves in the roadside spring, the one on the high side of the road, where the spring pours out at chest height, like a shower.  They wear only underwear or a lungi (fabric wrapped sari style around waist or chest)

• A man walking with three lengths of thick 3m long bamboo on his shoulder.  I am not sure why.

• A hay truck overloaded, but with one person asleep right on the top.

• A group of goats being herded along the highway by a man with a stick.

• A man climbing up the side of a bus as it drove in front of us, probably to adjust some luggage on the roof racks.  It is traditional, but recently illegal to ride on the top of buses in Nepal.  It is widely practiced, however, at times of transportation shortage.

• An obvious landslide that had jumped the retaining wall to land on the side of the road.  The traffic detoured around the obstruction.

• Multiple people waiting for a bus with a medium Winnie the Pooh shopping bag serving as luggage.

• Three school age children, pushing a bicycle cart loaded with rubbish.

• Multiple decorated trucks with messages painted across the tailgate – anything from “Stay back, please!” to “Push your horn!” “Limit Speed, Long Live!”, “See you” and “Buddha was born in Nepal”.  There are also various pictures of Hindu gods, playboy bunnies, pictures of the sun, Nike swoosh, Facebook icons and hands making peace signs.

• A man pushing a market cart with festival bracelets in bright colours displayed on multiple horizontal rails.

• An old man dressed all in white with a bright orange turban and no shoes, with two baskets on a wooden pole balanced across one shoulder.

• Two elderly ladies with grey hair wearing saris, holding hands as they walked down the side of the road.

• A man peeking over the edge of the roadside, presumably to see how steep the cliff was.  Or maybe he dropped something.

• Multiple men on multiple occasions peeing off the side of the road.  It makes me wonder – is this illegal in Australia? Or do people just prefer to find an enclosed toilet?

• A boy on a bicycle, being passed by a family on a motorbike, being passed by a truck.

• A woman with a towel wrapped around her head like a hat, which makes me think Douglas Adams visited Nepal.

• A man holding three heavy looking metal doors sideways between himself and the driver of his motorbike.

• Two women washing their clothes at the side of the river.

• A small car, which had been driven down the bank of a river, into the shallows and was being hand washed.

• Multiple white sheets laid flat on the ground next to a river, clearly freshly washed.  I see this one often and I wonder how white the underside of the sheet is. Maybe they lay that side against the mattress.

• About three million Nepali men under the age of 35 wearing checked shirts. It’s endemic. 

• Four bicycles in a row with a huge bag of rice (about up to my waist) wedged in the rail of the bike.  One of the cyclists was actually managing to ride the bike despite the bag of rice.

• Statues to hindu gods in cages on traffic islands. I assume this is to protect them from cars jumping the traffic island, as everyone is very respectful of religious statues here.

• Multiple small children running freely on the side of the highway in front of their houses, no cage or fence in sight.  (Reaching adulthood is a privilege, not a right).

• Three solders in camouflage uniforms riding bicycles with rifles slung over their shoulders.

• A truck completely on its side on the side of the road, with a single person transferring the contents by hand into a second truck.

• Another truck, this one sitting up on a jack with a man under the left front wheel, fixing something.  A small boy was sitting by the right front wheel (the same side as the traffic) so that people would know to go around.

• A pushbike with six chickens hanging upside down from the handlebars.  I assumed at the time they were dead.

• A monk riding a bicycle with a second bicycle strapped crossways to the luggage rack behind him.

Nepal, you are an amazing, beautiful, wondrous place, and you keep on surprising and delighting me.

Photo credit

Since I last wrote, we have been on holiday and caught up with friends, the season has changed and the rain has stopped.  I have lots to share, but no stories spring from my keyboard.  It is not that I don’t have thoughts, questions, dilemmas.  Usually, the act of writing helps me clarify my thoughts, helps me work through what I feel and think.  But sometimes the words stay muddy, the thoughts are tangled and the ideas crowded.

Thinking about it, I realize that I share the parts of my mission experience that make me passionate and excited, but only once I have figured them out in my head.  I should share that this life is not always like that.  Sometimes the thoughts swirl and don’t become clear.  There is no happy ending and no moral of the story.  I’m not sure about other people, but at these times, I really end up feeling a bit itchy and cranky – my brain is turning over various ideas, and don’t even know if I am content.

I want to explain about how visiting short term surgeons make me question my role.  Do they wish they were long term doctors, or do I wish I was here for a much shorter time? Do we have the same reflections, growth and memories when we relax on the plane on the way home?

I read the words of other missionaries that describe their community as spiritually rich and uplifting.  I want to admit I don’t feel that spiritual giant feeling.  I have been working here for two years, and we pray about patients and we can talk openly about the spiritual side of being in a hospital.  But what I do here feels like what I did at home, except the people I am caring for are in much more physical and financial need than those in my other hospitals.  If I wrote a book about returning home from mission, would I admit that I don’t feel like a spiritual giant?  Or would I pretend?

I worry about my kids who look forward to the Australia they remember – baths and drinking from the tap (without filtering) and MacDonalds hamburgers and cricket.  They remember only the surface of our Australian life. When they remember the rest, will they be shocked? Will they even notice?  I worry about my youngest, who claims he hates Nepal and wants to go home, but lives in a world where he climbs hills and jumps off buildings and chases rat snakes on his way home.  I don’t believe him.

I want to talk about things I miss about Australia – bacon and lazy cafe breakfasts, going to the gym and walking my dog, but I think it will sound like I am wishing my time away.  I want to talk about the great parts of working in Nepal like operating on skinny patients, but also think about the worst parts of surgery in Nepal, like skinny patients who are septic who are actually sort of malnourished.  I miss a laparoscope that lights up the abdomen, and a diathermy that works without having to hit the foot pedal thirty times, but I worry about all the operations I haven’t done for so long.

I worry about getting multi-resistant TB, because I met a returned missionary who did. 

I look forward to speaking english, and swapping gossip with the random people I meet.  But I will grieve the progress I have made.  I will lose words that I struggled to remember.  And I remember that going home won’t change me into a raging extrovert. Language is not the only thing that prevents me from chatting with people.

I worry that my dog won’t remember me. She has had such an amazing holiday with her foster family.  What should I do if my dog doesn’t want me back?

I want to write about how crazy it is that our kids school uniforms are going to cost upwards of $60 per outfit, when tailoring a whole outfit here costs $2.50.  How is it that worlds can be so different, and labour so cheap.  And why does a school need emblems on their socks?

I want to write about sitting in the sun in front of the guest house, chatting to a visitor.  I know I won’t be paid to sit in the sun at home.  Then I remember I am not paid to work here either.  

I want to write about how I am looking forward to an ensuite bathroom and soft couches, and windows with insect screens that work.  But then I remember I will miss my big window seats and the geckos and the foster cat who snuggles at my feet.  And I can’t decide whether to look forward to the new or savour the current.

I want to discuss how people at home seem to be wishing us home.  Every conversation seems to end with “we’ll see you soon” like the next few months no longer count.  And every conversation with hospital staff here seems to end with “why aren’t you staying longer” and pointing out all the tasks we have to finish before we go.  And in between I feel like our remaining time belongs to other people – some people who would shorten it, and some who would stretch it.

I want to write about how I feel like I am cheating. We can still afford to live here, we have savings left, but we chose to leave.  I want a break from working here – from being on call every second day, and looking after burns and kidney stones and infected feet.  There is no question that is selfish.  I want to resist the urge to make excuses, but they bubble up inside.  Maybe I don’t need to be so self-centered.  Maybe a little bit of burn out would be ok.  Would it?

Our overseas life is just as complicated as any life I had in Australia.  Sometimes there is lots of confusion and mental struggle, but no wise, pithy answers.  In the meantime, I go to work, spend time with my kids, and start writing a thousand blogposts and letters home that never get finished.  Maybe some weeks are just like this.

Image credit: University of Oxford

One of the remarkable aspects of working in a charity-run hospital is the abundance of short term volunteers and visitors. October is one of the nicest times to visit Nepal – the mountains are more likely to be visible and free from cloud, the weather is mild and the monsoon is over.  Furthermore, the rice harvest is finishing, so (Hindu) Nepalis are caught up in festival season and visiting friends and families.

As a result, we have visitors – interesting people to meet, who dilute our small community, introduce us to different skills and give us an opportunity to look out at the world.

One of our visitors is an experienced paediatric surgeon form Australia.  He is someone I would probably never have a chance to work with at home, and even if I did it would be largely as colleagues, as I don’t normally operate on paediatric patients.  But here I can watch complex intestinal and perianal cases, and learn from his techniques.  As a group, we have the opportunity to discuss those cases we have seen over the last year who seemed confusing, frustrating and heart-breaking.  We can debrief and get absolution (“Those cases are simply hard and there’s not much more we would have done either), as well as get ideas and techniques for the next similar patient if they arrive in the next few weeks.

We also have the joy of having patients that we know well discharged after definitive surgery.  One of the patients being treated this week presented to us 12 months ago for his first operation, at just four days old.  He recovered well, thrived, and is now a healthy toddler. It is infectious to see his family’s excitement at having his final procedure performed, and exciting for us, too.

Another visiting surgeon has worked as both a general surgeon and a plastic surgeon. We regularly have patients that would benefit from fancy plastic surgical solutions, particularly.  Our alternate techniques require more time for healing and more obvious scars and deformities.  It’s very entertaining (as a surgeon) to see a racy solution to some of these problems.  And fun also to banter with a new surgeon who is familiar to Tansen, having been here before.

It is also the season to meet new people.  This last week we met a couple from Australia who worked here 16 years ago.  This time they came to visit with their children and our kids got hyper excited by Australian accents in their Sunday school class.  Plus as they bought vegemite, which we have not had for a month, we were predisposed to love them.  Next week we are excited to meet a new family who are considering volunteering to work here long term.  One of the great parts of working with such a diverse group of people is the variety – some mission heroes have been here for decades, some for a month or two, some are still considering, and some are returning.  It’s like joining a huge family reunion in a cacophony of languages.

At the moment, our expat, and even Nepali hospital staff numbers are pretty limited.  We have few GP’s to run the medical and maternity side, and we are running on a skeleton crew of surgeons.  Some of our senior staff are on leave, which accounts for some of the difficulties.  When a large proportion of staff are expatriate, then their holidays periodically involve travelling home for longer periods.  We also have reduced numbers of long term volunteers, possibly indirectly due to the earthquake last year.  Our regular periodic visitors all came last year to help, and our potential candidates maybe decided to serve in a different country.  As a result, we are feeling a bit “small”.  Everyone is working more, and serious patients who need round the clock monitoring (like intubated patients) add extra strain.

In the midst of that we get bursts of sunshine – visitors to lift our spirits.  Visiting surgeons to offer expert procedures, and advice.  New surgeons to share their excitement.  Newly qualified Nepali doctors who step into higher levels of responsibility and remind us that medical training is the bomb. And friends to debrief with, who bring vegemite and Tim Tams.  Sometimes God brings the sunshine just at the right time.

Image credit: Nepal Tourism

As I have explained before, there is no long waiting list for elective surgery in Tansen. If patients need an operation, we book them in on the next slot, which is usually in the next few days.  In order to have any “large” operation performed, patients need to provide one blood donor who donates a unit of whole blood (patients who genuinely have no relatives or neighbours are exempted).  For cases like lap choles, this blood is very unlikely to be used for the patient, but it forms part of their payment. It is added to our stock to be used for emergency patients when required.  Along with blood, the patients pay for their operation and hospital stay (about $200-300 US), and need to provide a family member who will look after the patient while they are in hospital, fetch their food from the cafe (or outside restaurant) and help them to the toilet and to mobilise etc.

The main difference with our operating suite is the lack of money for single use items.  This generally means we operate a lot more like MASH and a lot less like “ivory tower” hospitals.  

We wash in the sink, with soap.

Our instruments are a mishmash of reusable and single use items.  Almost all are donated.  All the single use items get resterilised and reused regularly. The nurses setup is very simple.  The gauze pieces get cut and packed, and sutured together before sterilisation – nothing is purchased pre-sterilised.

We only have one automatic ventilator, which is na recent addition, so often the anaesthetists (actually anaesthetic nurses, not medically trained) have to hand ventilate throughout the case.  No surfing the stock market.

Our laparoscopic ports are also reusable, and we use sterile covers on light and camera leads.  These items can be sterilised, but we are careful as our power supply is variable, a combination of generator and town power, that sometimes dips and surges like a mountain range.  Laparoscopic equipment is too precious to risk, so we use covers.

Unfortunately, we do have a relatively high conversion rate for cholecystectomy.  Patients arrive late for surgery and have quite inflamed, scarred gallbladders.  Also, we sometimes convert to open for technical problems, like electronic equipment malfunctioning.  In Melbourne I never would have considered to the need to convert to open just for recurrent power surges or a malfunctioning UPS (which keeps the stack running when the power is out).

Our operating tables are radiopaque, which makes operative cholangiogram difficult.  When we know there are CBD stones, we have no capacity to remove them laparoscopically, so we choose open CBD exploration – an operation I learnt for my exam, but never had to perform in Australia.

Nepali patients recover very well after surgery.  They are strong people and are typically used to working despite pain, and are rarely precious.  It is not uncommon for patients to have to walk one or two hours home from the main road after their operation, so we keep them a few days if they choose to stay – almost as caring as a private hospital back home!

I know the surgeons and surgical nurses amongst my readers will see the difference in our setup compared to a medicare funded system in the first world.  I’m sure my non-medical friends can look through these photos at the rooms we work in and realise our hospitals at in the first world don’t look like this.  But despite all that, this operation, and many others like it, are a link between the two settings.  All patients across the world need surgical services, and without them, their life would be shorter and of poorer quality.  Despite obstacles of poverty and resources, we can provide appropriate “best practice” surgical treatments, equivalent to what we would offer at home. 

And even more exciting, we can spend time training the junior Nepali surgeons to provide the same surgery.  If our laparoscopic capacity was lost, we would still be able to treat patients.  But the guys in this photo who will be surgeons in Nepal for the next forty or fifty years would lose the chance to learn laparoscopic surgery safely.  It is possible to perform “advanced” surgery in a low cost way, with cheaper equipment and less disposables.  Although we daily make decisions about utility and value, we are proud that we can perform laparoscopic surgery, and our arthropods can perform joint replacements and spinal surgery, at a high and reproducible quality.

When Luke first arrived, he spent time getting to know everyone – stopping to have chiyya with friends and meeting everyone in the bazaar. Now, around the tea dates, he is busy everywhere, nipping in and out of the compound on his motorbike, managing varied projects, and it seems like the only time you can count on him being free is when I am on call.

I will share just a few of his projects. Luke is a computer systems engineer by training, but has worked in fairly high level of management as well.  In Nepal, he has worked alongside engineers with various expertise (water, civil and biomedical, amongst others), builders and tradesmen, workshop and hospital IT staff.  He has has a talent of identifying big questions that need the advice of the person who he has next to him at the time.  This means the more people he meets, the more diverse the projects he ends up working on.

He has a good friendship with the local blind community, who needed to rebuild their residence after the earthquake.  He has kept an eye on the project and helped them troubleshoot problems as they occur.  This even led to him helping dig a well, when they hit an unexpected spring!

After the earthquake, Luke was considering the hospital supply logistics (which almost certainly means he was chatting over tea with his hospital friends) and realised we rely on external oxygen supplies, which are trucked in over landslide-prone roads.  So he and the Biomedical engineers reaserched the problem and realised we could install an oxygen concentrator, and make our own!  With a good business plan, he helped arrange external donations to support the project, as it will pay itself off very quickly, due to the high cost we currently pay for oxygen.

The plant is now installed, in a new little building, and as a spin off, he was able to install new oxygen piping through the hospital.  As happens with this project, extra requirements got added on – the update of the hospital’s medical air supply to “medical” air, as opposed to “just” air.  They were also able to relocate one of the compressors that was causing a lot of noise pollution, to make a nicer environment, and also create more room for other hospital equipment.  

And of course, to make good quality oxygen, we need to have smoke-free air.  Luke (and Tim) helped research and plan a new waste incinerator.  The new incinerator burns hotter, to reduce the smoke and fumes, and the guys were able to identify the particularly toxic smoke producing waste and come up with a plan to reduce its effect.  And if you have to have a new incinerator, make sure you have one with a view…

Other of Luke’s projects fall outside the compound.  Through our friends, he met a spinal injury patient who had limited mobility in his home.  Nepali houses are often two story, with a large open area for cooking on the ground floor and a sleeping area up steep stairs.  

This guy was unable to live as he normally would, because he couldn’t access his house with his cross-country wheelchair.  So with a little cash some ideas, and a lot of  help from his village friends, Luke and his friend, Ganesh, were able to help this guy make small renovations to his kitchen door, his porch (making it one level), install a first level sleeping room and make his life a whole lot easier, we hope. 

Certainly, that may be true. Luke often discovers problems when chatting with friends and hospital staff, and ends up finding ways to pitch in, support and help.  There’s more of these projects than I have mentioned, and there are more that he finds out about every day.  However, by solving one problem, the next similar problem is easier to solve.  And he works with a consistent team of hospital and outside workers, who all learn as well.  As always, when the sun goes down, they can celebrate with a  cup of chiyya.