Re-do day

Friday has come very quickly.  We made our way into work with our trusty assistant, Hemanta.  He drove us a new way today to show us some sights, and made a stop from a bicycle vendor to buy grapes for the OR crew.  He said most of this fruit comes from India, the neighboring country to the south west.

Excited to take in the new equipment I brought to spiff up the machines. All calibrated and ready to go!

Sadly our patient from yesterday did not have good outflow from her free graft.  She had to return to the OR and was given a graft from her radial area (skin and fascia) and after a full day again, it looks beautiful.  A difficult thing to have to do, but a very valuable lesson for the team to see and work through with their expert Dr. Megee while he is here to guide them through the process.  There will be more failed grafts in the future, but they have been through the fire drill and now are armed with the knowledge to deal with this situation.

For those of us who recycle, if you need to feel discouraged, come to Nepal after an earthquake!

Brick fence down around a compound; razor wire goes up.

It has been a long week and I skipped dinner to go supine.  12 hours later, I feel ready for more!

Another day, another free flap

Front of our hotel has some sample views of what can be seen in Nepal, peeking up alleys and around corners.  Beauty and colors!

Carving and details.

Flags and weather.

Driving in, we see many cows in the road - walking, sleeping, grazing.  They are considered sacred, and if anyone injures or kills a cow, it is worth 20 years in prison.  Pretty harsh, but at least it keeps traffic under control. 

Resurge support staff bringing snacks to the OR.

Clever tourniquet looks like a bicycle pump.

Flap number two today - rectus abdominus to anterior tibial vessels and defect.  Luckily did not have to do 7 hours of prone with make-shift padding again.

More beauty just outside the OR window.

Finishing flap; just needs skin graft to seal it over.

Sweet anesthesia assistants and anesthesiologist.

Small free standing machine; just like the Resurge design.

Walk around the corner of the hospital - lillies!

Tent encampment on the way home; one of many.  

Up to code?  This was my first thought when I heard of the earthquakes - all that wiring.

Many tall but tiny free-standing buildings.  Conserving space.

Down time at dinner!

Gecko visitor in my room.

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.