Paper or plastic, or not

 

One thing you won't see much of in Bhutan is disposable paper and plastic goods.  Even in nicer restaurants and the hospital there are no paper (or cloth) towels at the sinks, no boxes of kleenex, and it is strictly BYOTP.  Plastic shopping bags are taboo--a step ahead of Oregon on that one. The only common disposables in the OT are masks and hats; suction tubing, cautery pens, cloth drapes and gowns, plastic aprons, all get used until they are literally falling apart and every suture is used right down to the last inch.  I was warned not to strap the patient's arm  to the OR table armboard because it has been known to fall off and can break the arm!  Paradoxically, we had a nice new Ligasure device for the mastectomy this morning, and Dr. Tashi did his open gastrojejunostomy (bypass for obstructing distal gastric cancer) using a disposable laparoscopic stapler, firing two "magazines,"  a case tht could easily be done using just a small selection of sutures.  CTs and MRIs seem to get ordered more or less wtih abandon and almost every patient has a pre op CXR.

One particularly poignant case on the ward right now is a petite young woman who suffered a complete transection of her common bile duct during a lap chole at a smaller hospital.  It was recognized and repaired immediately,but unfortunately the t-tube was accidentally pulled out 4 days after surgery.  She was watched for another 3 days with bile pouring out of her drain until we took her back for a clean out and new drain today; normally her bile duct would have been stented immediately but ERCP is available only by travelling to India or waiting some undetermined time until our GI specialist is in town. 

A child recovering from skin grafts has some company from his sister and her ipad.

I did get to do a mastectomy today--I had to think it through carefully to figure out how to improvise with the tools and materials at hand.  You don't ask for a certain suture as if you were ordering off the menu in a restaurant; it is more like you come home and look in the fridge and see what is available.  The room seemed packed with people, including another surgeon pressing in to look over my shoulder until he was practically leaning on me.  The nurse anesthetist, however, spent much of the case intent on an iPhone in a corner of the room.

The neurosureon and his electric drill are in Katmandu, so General Surgery does the Burr hole with a very dull hand drill.

The surgery ward continues to have a wide variety of cases that harken to the days when General Surgeons really were the multitools of the operating world:  burns with skin grafts, leaking anatomoses from the district hospital, subdural hematoma, chest trauma, ureteral stones, hepatocellular carcinoma and always a few cases of obstructed gastric cancer.

Lunchtime potluck:  Chilis and noodles, chiles and rice; beets, green leafy veggies, milk tea.

Strangely, I have had opportunity to use my Spanish here!  Last night I was invited out to a big banquet for a hematologist from Australia who is leaving, and spent the evening chatting in Spanish with a Cuban pathologist and her brother, an ENT, both working on a two year contract.  Also, a number of residents and doctors have trained in Cuba and are fluent in Spanish--very disorienting to carry on a conversation against a background of Bristish English and Bhutanese!