Let the microsurgery begin

 Every morning on our way into the hospital, we can see the many who are still struggling to find their way back home.  Make-shift lean-to spaces, organized communities of Chinese-donated tent-homes, or simply those sitting on the sidewalk looking lost.  The city is slowly consolidating the rubble and making its way back to the usual buzz, but the rebuilding and return to normalcy will take time and energy.  Most of the city stands and is back to work, but without many machines to help, it is still heart wrenching to see families reclaiming their homes, stone by stone. 

A problem for us in the US is the overabundance of trash we generate in hospitals.  Everything is wrapped individually - sometimes by many layers - and the multiple bags of trash per procedure are mountainous.  A technique they use here is to flash a tin of needed cloth (not paper) gowns, drapes, wraps, or whatever is needed for the patient in question.  Here is one of the metal tins with a holder for tongs.  The holder has been sterilized, as have the tongs, but a non-sterile non-gloved person uses the handle to reach into the bin and pull out the sterile items.  That also saves on gloves, and allows many to step in to help if needed.  It will make many cringe who deal with infection control, but it works and in this setting saves so much in resources.

This is taking place at the bedside of a burn patient in the recovery area.

We had one major case today - our first free flap using the microscope and the latissimus dorsi muscle.  These two photos show Drs. Pramila and Kiran working to free up a portion of the back muscle needed to donate to the leg.  Without covering the wound he has, he probably would lose his leg if not his life from infection.  The flap is a portion of muscle with its overlying skin and a vein and artery found that can be used to attach to a vein and artery found in the leg.  In its new home, the muscle can fill in a defect and heal over to protect and return intact skin and bulk to the leg.  Sorry if this is too gorey for some of you, but it really is a thing of beauty.



Many hands make light work.

 Here we can see the two teams at work - harvesting the flap and preparing the leg to receive it.  Once the gross dissection is done in the leg, the microscope is moved in to facilitate anastomosing the blood vessels from the flap and the leg together so that the blood will nourish the flap once again and the healing can begin in its new home.  Dr. MeGee is the expert on this procedure, and he is guiding the two local surgeons through the procedure.  Eventually he is sitting on a stool away from the table, and Drs. Nakarmy and Rai proceed with the flap placement.  We will do several of these same procedures to give them a chance to perfect their technique.

As with any OR, but especially here in warm Nepal, cooling is critical for the surgeons in their layers of gowns.

One of my favorite patients so far - this is the gentleman who was tending to his animals when the earthquake buried his leg and he has been here since.  He has a very infectious nearly toothless grin that broadcasts his determination and appreciation.  He lay through a long procedure under spinal without sedation, and for the hours he was there, whenever I  peeked around the drape to see him, I got that big grin.  He is shown here heading back to the ward for wound care.

And speaking of happy smiles - these are two of the wonderful ladies with whom we work alongside.

One of the four workers funded by the cafeteria profits, keeping the floors swept and the patients in a comfortable space.

The cables shown the other day disappearing into a building wall as seen from the hospital, with trolley swinging in the wind.

Right next to our view of the valley, the trees, and the trolley is a board with essential information for each case.  A big step to help with documentation for cases.

The graft has been brought into place, wrapped around the wound, attached to its new vessels, and voila!  It is a thing of beauty.  Over time, the muscle fibers will atrophy and soften, and it will look right at home.

Never ceasing to amaze - Dr. Rai mops up after the case, and then was spotted cleaning the bed after the patient was moved in recovery.  He is forever setting an example and doing what he can to make everyone feel equal.

  

We all made our way home and headed for the rooftop cafe to have some unwind time.  It is exciting to see all this work, but it is stressful for us out of our comfort zone of routines and systems, unlimited resources, and easy communication.  But we are surrounded with people determined to make it work and that is the boost we need.

Cases and teaching at the bedside

This morning Shankar drove us all in to the hospital. First we stopped at Model hospital to see a patient.  There has been earthquake damage at this hospital, as you can see by the cracks in the balcony.  The upper floor had to be evacuated, and many patients were taken to Kirtipur.

The patient that we saw is 28 and had suffered a burn on his scalp many years ago.  Over time he has developed a Marjolin's tumor or ulcer, which is an aggressive form of squamous cell cancer that forms in scars.  It is now invading his dura and sinus, and although is has shrunk in size with some treatments, there will be no cure.  His CT scans are quite impressive and unfortunately his outlook is not good.  He is already having weakness on one side and other symptoms.

Once we made it to Kirtipur Hospital, Shankar gave us a real tour.  His potential for expansion and dreams are very great, and his enthusiasm is limitless.  He is determined that this facility will take care of all comers and provide care to the poor.  He is currently struggling to get his colleagues to accept this vision, as many drivers of career choices involve income.  But something tells me he will prevail.

He is adding a new OR suite for all kinds of surgery, a PACU, ICU, and other areas.  In the photo above, he is showing us a ward that they populated with beds in case they needed them for earthquake injury treatment, but they were able to take care of everyone who came upstairs.  He said they sent no one away and treated the hundreds of patients who came his way.

One of Shankar's innovations was the cafeteria.  He makes sure that each patient and one family member get meals.  Anyone who buys meals is putting money into a hospital fund.  For example, there are 4 people employed by the cafeteria who clean the hospital floors each day.  Shankar hopes to deliver food to local businesses and schools for a price, enlarging the cafeteria funds.  As the money grows, they can decide which project to fund next.

 
Dr. McGee operating with local maxillofacial surgeon.  This young man of 16 had an enlarging AV malformation on the left side of his tongue and was faced with a possible hemiglossectomy.  A more conservative plan was utilized, to sclerose the mass by injecting the blood vessels with a sclerosing agent..  All went well.

The PACU is packed.  They keep all patients overnight here after surgery, and some patients have come before surgery to be hydrated, have dressing changes, and be ready for surgical care.  All ages, genders, and wound types gather here.  Cynthia is helping where she can, but the biggest obstacle is having the staff develop and follow protocols for the care they give.

There is one patient in the PACU who is over 70% burned.  Even in the best of centers, her care would be prolonged, painful, and expensive.  Here in this small unit, she is being treated as best as possible.  Our team had suggested that maybe this was beyond our reach, but Shankar will not give up on her.  Tomorrow she comes to the OR for clean-up and re-evaluation, but she will be given every chance to show her potential to survive before the efforts are turned to comfort only.

Patient family waiting in beautifully colored local dress.

Cynthia supervising administration of blood.  As the patient had no armband, checking the blood to be given was a nightmare for us who check blood in the West.  The nurse brought the blood over and began to hang it, and I had to stop her and make her check with me that it was the right blood type, unit, and patient.  The son had to identify the patient, and as Nepal uses a different calendar year, I was sure the blood was expired.  But it was truly for June, not February (Nepali calendar, http://calendopedia.com/nepalese.htm), and the patient got his needed care.

On closer look, you can see the clever way the blood is being warmed.  The bottle hung from the IV pole is hot water and the tubing passes through it.  Otherwise blood is chilled and can cause a patient to shiver.  This patient was already a few degrees below normal temperature, so we had to do something quick.  Fluid resuscitation is quite behind in all of these patients, which we hope to remedy.

Lunch break.  Rashmi is one of the scrub techs, and she began sharing her lunch with everyone.  The generosity and comradery are amazing here.  Also seated are the maxillofacial surgeon (have got to get her name today!), and Richard, our team circulating nurse.  Richard is struggling with issues of sterile processing and set-up of sterile equipment.  He is learning the obstacles they face here, but also there needs to be more attention to sterility.  He is mulling over how best to help and this chapter will unfold as we go.

Older gentleman who was tending his animals and got hit by large rocks and rubble.  He has a large gap in his tibia, which the frame will help bring together, but meanwhile the area had to be covered to keep out infection and allow healing.  Here the pedicle flap made from the soleus muscle is fanned out to cover the shin area. 

Mohan manually cross-hatching some skin to span over the new flap.

Voila - finished product! And a chance to heal and survive.

 

First day, rounding for possible repairs

Cynthia and I met for breakfast and found David McGee there as well.  We then saw Richard, just arriving from the airport, and all got ready to leave for the hospital.

Many parts of Kathmandu that we passed seemed unchanged, although occasional piles of rubble gave away the truth.

We arrived at the hospital, and to my delight, since my visit almost 2 years ago, many details and areas of the hospital are now complete and one can get a better grasp of the vision Shankar has for his hospital and patient care in Nepal.  There is a pharmacy, entry lobby, dedicated physical therapy space, teaching rooms, and endoscopy suite in addition to patient wards, surgery suite, and recovery room.

The surgery suite was filled to the max with many very complicated patients with long roads to recovery.  But for each patient this surgeon has a dream and will not bow to obstacles.  Yet when it is put to him that a patient is really beyond his or anyone's help, he is able to respectfully agree and move on, with a plan to speak with the family and try to resolve the situation together.  You can see that he is universally trusted, adored, and respected by his patients.  With good reason.


These photos lovingly obtained with patient permission, so please do not share or abuse. 

This patient was trapped in rubble for 3 hours with her toddler grandson, who survived without major injuries.  She is missing part of her tibia bone, and the orthopedic doctors have put on an external fixation device to provide the leg a chance to be stable.  She will get a flap of skin and muscle, moved from another location, and placed over the wound.  Bone that is not covered does not heal and often leads to serious chronic infections, so closing the wound is a priority.  Whe will then get more treatments to provide the bone a chance to heel.

Lots more work to be done on this patient; the xray shows many loose fragments, a floating patella, and a collapsed joint space.

There are several patients with devices I had never seen before - the Iliazarov apparatice, meant to bring bone together that has not healed or has a gap to bridge.  These devices cost a fraction of what they would in the west, but at $400 they exceed the $250 that is paid by the state for each patient's care.  The fact that these patients are getting such care in this small and energetic place is quite amazing.  This gentleman was tending his animals when the quake hit, and his leg was damaged by falling stones and debris.

Another creative orthopedic repair - a clean wound but still bone exposed with nowhere to attach.  They are talking of placing methyl methacrylate as a kind of spacer while the wound is covered and treated, then a bone graft or other treatment can be done in the future.

Team talking about issues.  Shankar shared with us that many people in this country use healers who talk to the gods.  They don't send people to other specialist healers for certain gods and keep others.  This makes it hard to get patients to understand the concept of referral, and they start to believe a doctor is not good if he cannot do everything.  This pressures every facilitate to try to treat all things, even if there is a better location.  Then there are the financial aspects - some hospitals pay the ambulance for each patient it brings them, and then inflates the cost of care enough to cover the ambulance incentive.  This inflates the cost for the patient.

I love the new tricks I learn each time about how to reuse and save opening new paper packs at every turn.  This patient, about to be prepped for a debridement, has his leg over the glove and supply wrappers to catch drips during the process.

Dr. McGee at work, cleaning an old wound with new colleagues.

Literally a "window box"; viewing complicated xrays by the light of the sun.

A bone disaster, with Kathmandu in the background, also broken in many places.

We have an expensive device we use in the US which is like a power washer with batteries, fluid, and suction.  The wound can be cleaned and suctioned at the same time.  Each time the device is discarded.  Here Shankar and team are using a 60 ml syringe, bowl of water, and metal tray to catch the water to be suctioned away.  Almost the same thing, at a great savings.  There are so many gadgets we have that we would love to share, but then the hospital and staff become addicted to the disposables and possibly a machine that may break and cause them more problems than help.  We have to be careful where we interfere with new products, because the team is often on its own better path.

Shankar debriding a hand with severe burns that will need skin grafting, if the patient survives.  He may lose one or both legs, but getting him clean of the infected and dead skin is his only hope at survival.

Dr. McGee and Dr. Shankar at work.  I love the way Resurge doctors come together with that "let's do this" attitude.  As educators, we are here to help, facilitate, and try to interject procedural changes where they are seen by all parties to be a helpful improvement.

Sometimes the plastic avoid or recycle activist in me squeals with delight at the signs of reuse and conservation that happen in an effort to squeeze every ounce of use out of an item.  The hospital wins, and so does the environment.

Bad monkey scampering down the scaffolding, looking for a hand-out.

Ambulance - simplicity in most.  Grab and go with bed and oxygen.  The rest is speed.

Some of these tiny roads are barely wide enough to walk, and yet vans pass each other with stone walls and no forgiveness on either side.  I was sure we were going to have to pull the rear-view mirrors in, but we made it!

There is a tram/trolley device that goes from outside the hospital up the mountain in one direction, and down to the valley in the other.  It has not functioned for years, and the Nepalis cannot afford to take it down.  So they built around it, and it can be seen piercing the walls of many structures as it meanders down.  

More rubble, and a family at work.

Deck folded over.  I hope no one was sitting there.  Natural disasters strike without ample warning, and the consequences are severe.

To the rooftop at the hotel for some food and cheer, and then all off to bed.  Much work to be done.

Recharged and ready June 7, 2015

As usual, the flights were long and crowded.  Getting more and more crowded, it seems, and not just the flights, but the airports as well.  Throngs of humanity, all with their duty-free, masses of bags and stuff.  Garbage bins overflowing on the floor.  Out of forms because too many visitors.  Bathroom lines out the door.  Nowhere to put things on the plane; overhead bins crammed full and no real leg-room.

We passed through Abu Dhabi on the way here, a shopping mecca surrounded by land that is all one color - sand.  Even the roofs and roads all blend together. 

Flying in over Kathmandu in the dark revealed few lights and many open fires until we were right over the city, and even then it had very low illumination for a city of this size.  The air quality was hazy; almost fog.  My bag never showed up, so now I am in the vortex of bag-recovery mode.  I will be fine, but brought almost a bag full of things for the OR.  We will see what happens with that over the next few days.

It was dark on the way into the hotel, but we could see that most of the roads are cleaned up.  Most of the rubble and debris are swept and piled into stacks alongside the road.  "There was a house, and now is bricks," commented our driver.  We certainly will see more of that today on our way south to the hospital.

We are at a hotel familiar to me from my last visit, and all is comfortable and friendly.  I had to deal with the desk clerk about my bag and he asked what was my "good name".  Very sweet.  Great breakfast, those of us who need to be here are here.

This morning we are going with Dr. Shankar to a Ministry and get registered as medical workers.  We get to see the bureaucracy at work - or not - and then off to Kirtipur for our first day.

We are all showered, rested, and ready to go.