Operating with one hand tied behind your back: A day in the OT with Dr. Sonam

Dr. Sonam plays candy crush while waiting for turnover.

The Bhutanese medical lingo is infused with a special flavor of British English, filtered through the Indian education of most of the doctors.  So there is no OR, but rather the OT:  Operating Theatre.  I am addressed formally as "Madaam"  (rhymes with aplomb), and the male doctors are "Suh".  More informally the support staff refer to each other as "sista' and brotha'".

Our first patient had been admitted the night before, as usual for gallbladder surgery, but on applying the monitors in the OT she was found to be severely hypoxic and hypertensive.  Our advertised 9:00 start drifted toward 10:00 as the next patient was fetched and prepared.  I felt like a brand new intern trying to "assist" Dr. Sonam:  first, a scrub with a bar of strong smelling soap, then finding right side up on a heavy, wrinkled cotton gown, which had to exchanged due to a large hole in the sleeve.  Double gloves, but no closed gloving technique.  Dr. Sonam preps with a cottan swab dipped in a metal bowl of iodine.  Drapes are heavy multilayer green cotton, arranged and folded just so, and held with towel clips.  All the laparoscopic equipment is reusable, or at least re-used:  unguarded metal trocars with little caps that flip up and down for 5mm and 10mm instruments; others are yellowed plastic, the irrigation is hung in a plactic bottle and squeezed by the anesthesiologist for more pressure.  Once started, Dr. Sonam works slowly and carefully, stopping to dip the tip of the scope in a thermos of water (hot or cold?) to clear the lens.  I crane my neck to see the one monitor, which suddenly looses color and goes to black and green with flickering red lines.  Dr. Sonam sighs, and the anesthesiologist jiggles the power cable until color returns.  Nevertheless, a gallbladder is safely removed.

Next up:  two patients for cystoscopy and removal of ureteral stents.  No IV or monitors; the anesthesia is "local and vocal":  lidocaine jelly and gentle reassurrance.  As the scope clears the prostate and enters the bladder I see brown toes curl tight, but there is no sound.  The stent is pulled clear, demonstrated to the patient over the drape, and tossed aside.  Next, a petite young woman walks in and hops on the bed and the process is repeated.  Feet in to feet out is not more than 6 minutes.

We nearly suffer a "cancellectomy" as electrolytes are re-checked and high risk consent signed for an elderly, emaciated man with obstructing gastric cancer.  While we are delayed, we retire to the staff lounge and Dr. Sonam treats me to hot milk tea and a bowl of microwaved dry noodles.  As more staff arrive for lunch small dishes from home are shared around the table and soon my Ramen is doctored up with leafy greens, sausage and chili.  My fingers are crossed, hoping for no inter-cultural exchange of microbes.

Back in the OT at last, our patient is no sooner asleep and prepped than the incision is made without any preamble or interruption of the multiple conversations taking place among the 10 or so people in the room.  Again Dr. Sonam proceeds with not much more to work with than a knife, a fork and a spoon (okay, no fork or spoon, but only two varieties of retractor and some vicryl).  In just a short time he has a nice gastro-jejunostomy and we are done for the day, exactly 2 minues before the usual quitting time of 3:00 pm. 

I'm sure this is roughly how surgery is done over much of the world.  At least Bhutan has the benefit of well trained, compassionate doctors, willing to do their best with one hand tied behind their backs.  Will I soon be giving it a whirl?

Street shoes stay outside, just like in the temples.