shake that cat

Two days, seven sites

(Above, Dr. Paudel, orthopedic surgeon (L), and pants surgeon (R))

Today has been a slow day at the hospital, most likely due to the strikes (bandh) taking place in Janakpur and other smaller towns that closed the roads to traffic, keeping patients from getting here (the physician in charge of the hospital, returning from Kathmandu today with family, had to talk his way past several roadblocks). So far my attempts to figure out what the strikes are about are met with vague talk of "politics," as it seems no one wants to delve deep into a discussion of Nepali politics, at least with this foreigner.

The previous two days, however, have been full ones, as I've spent both with Dr. Paudel, the orthopedic surgeon. Tuesday is his scheduled day in the operating room, and I was able to join his team as they were getting started on the day's surgeries. First up was not really surgery, technically speaking - for the gentleman who had forearm fractures set with open reduction and internal fixation last week, Dr. Paudel checked the range of motion and whether the fracture remained properly set, which testing would have been extremely painful for the patient had he not been sedated. A 14-year-old boy had a separated shoulder set with an open reduction, two gentlemen had foot ulcers cleaned (and in one case, skin-flapped and skin-grafted), and the last gentleman had a small piece of glass under the skin of his forehead he wanted removed. He had been warned that it was so small we might not be able to find it, and that turned out to be the case.

I'll admit this was my first time viewing actual surgery, so I don't have much "here's how it works in the average American operating room" experience with which to compare, but I'm guessing that most American operating teams don't take tea between operations, period, never mind as a complete team, and as far as I'm concerned, that lack falls squarely into the category of Things Wrong With American Medicine.

Wednesday was a completely different experience. Instead of spending an eight-hour day entirely in one room (except for a few minutes in a small side room for the aforementioned teas and lunch), I accompanied Dr. Paudel as he left the hospital grounds at 5:30 a.m. to visit small medical clinics/pharmacies between here and the town of Sindhuli, 30KM or so away.

I am a complete wuss (and no, that's not a medical term) when it comes to motorcycles, so while Dr. Paudel is an excellent driver, it did take me an hour or two to unclench my knees and hands after riding on the back of the motorcycle most of the day. The first half of the route to Sindhuli is paved, but the second half is narrow and unpaved, covered with a mix of gravel of various sizes and the occasional patch of sand. The route winds through beautiful hill and river valley country, and given the width of the road and the lack of a center line, standard procedure is to lean on the horn when approaching any kind of blind curve or hilltop, just in case there's a huge Tata truck or bus coming around the corner from the other direction. The motorcyclist is also keeping his eyes peeled for pedestrians, livestock, and recently-felled trees in the roadway. So I'm hanging onto the back of the bike, with the bicyclist part of my brain that never did like gravel roads or sandpits trying to ignore the fishtailing sensation that occurs every hundred yards or so, trying not to lose my grip every time we hit a good-sized bump in the road, all the while thinking, "If I get bounced off of here at 50KM/Hr, I'd better do it in such a way that the driver and the motorbike are left otherwise undisturbed, because the driver's the best person within a couple hundred kilometers to reassemble me after I land."

My wussitude aside, Dr. Paudel's goal for the day was to drop in at several small combination clinic/pharmacy establishments and at the hospital in Sindhuli to network, press the flesh, and generally direct some orthopedic surgery business his direction. At every stop that involved some impromptu examining and consulting, whether orthopedics-related or not, regarding patients who turned up at the establishment we were visiting at the time.

(The first stop also involved some impromptu zipper-replacement surgery, pictured above, on the surgeon's pants.)

Shortly after we wrapped up the visits in Sindhuli proper, Dr. Paudel's cell phone started ringing every couple of minutes, as new cases requiring his attention had arrived back at his clinics near the hospital. That urgency increased the KM/hr of the bike and with it, the terror on the back of the bike, on the return trip. Four children had broken arms in unrelated falls; three of those were treated with casts and slings, but the fourth, a girl of about 4, had a fracture and displacement that needed surgery to fix. The usual rate for that surgery was 15,000 rupees (about $215), but because it was clear the family couldn't afford the fee, and because the girl had been brought to the cooperative clinic (where Dr. Paudel could set his own fees), he offered to perform the surgery for half the usual rate, and possibly would have reduced the fee significantly beyond that. But the family apparently misunderstood the offer of the reduced rate, and left without making arrangements for the surgery. It's possible that they'll make arrangements elsewhere, but the most likely result will be that the little girl doesn't get surgery at all and is left permanently disfigured.

14 hours after we started out for Sindhuli, Dr. Paudel had seen patients at six different sites. A reader asks, "Have they figured out what you are going to do yet?" and the short answer is "sort of," but the best idea yet came from a member of the staff at the last stop of the day, who suggested that I park myself out in front of the clinic, as an advertisement to the effect of, "foreign doctors practice here." My advanced age probably makes pulling that off easier for me than for most first-year students, and frankly, work as signage is less hazardous to patients than most other uses for first-year students.