From Khovd – Last day: September 21, 2010
The past few days have been focused almost exclusively on work, doing surgery, and not a lot else. That we are almost at the end of our 10-day stay comes as a bit of a surprise, if for no other reason than it seems to coincide with the autumnal equinox and a significant drop in the temperatures, especially at night. For that, I am glad that my long underwear and fleece keep me comfortable, if not a bit warmer. This morning, I took a lukewarm shower in my room, which was 58 degrees F (14C). I think that something like hot water, which we take for granted at home, will be much appreciated for a long time.
I did a hernia repair on a three-month old the other day, and while the operation was not particularly strange to me, doing it in an atmosphere of such anticipation, with an audience in the OR of about 20 people certainly was. There is not much pediatric surgery done here, primarily because of anesthetic considerations, but our anesthesiologist is skilled and comfortable with doing the little ones, and so we proceeded. My instruments however, were not suited for children, and I did the best with what is available: a huge surgical blade to incise, about the size used for autopsies, and dissectors almost as long as the baby himself. It all went well, and everyone was pleased with the result, especially the mom and grandmother.
Because there were a number of surgeons visiting the Khovd Provincial Hospital for this project, we were asked if we might give up our free day on Sunday, and do surgery instead. Of course we said yes, with the simple question being, “Why else did we travel all this way?” It was a productive day, and with lectures interspersed with the surgery, we did get a lot done.
We just celebrated at final dinner together tonight at a restaurant hosted by the director of the hospital. While we all expected the usual mutton stews and its derivatives, to our amazement, ovines were nowhere to be found on the menu. Instead, there was a small salad that included red beans, cucumbers, tomatoes and such, and a smoked whitefish that brought back all kinds of memories of family breakfasts. The skin on this lake fish was quite tough, and the salt content made up for all the deficiencies in that department I have experienced in the cuisine here so far, but otherwise, it was identical to the usual smoked whitefish that is typical elsewhere. In addition, the soup was served in a fish broth, and the entrée was a fried freshwater fish from local waters. Who knew that fish might be part of Mongolian cuisine, after the past nine days of mutton and its variants? Members of our group have eaten marmot, but that four-legged creature is a far cry from having scales. Anyway, the fish was good, and we all enjoyed our meal.
Of course, no large meal in Mongolia is complete without the requisite toasts to the visitors, the hosts, the members, and all the other people who made the trip possible. There was a nice turnout by all of the most important people with whom we had daily contact in the hospital, and I could see that there was a gradual acceptance of our presence around the facility that moved beyond what I had expected it to be. As the nominal medical director of the group, I was called upon to make the first of the speeches, and in my remarks, I commented about something that was not obvious when we first arrived here.
As I mentioned in my initial email in this series, the issue of sustainability has been sorely lacking in my other trips, where we have practiced “parachute” medicine, coming in an area for a few days, doing a lot of cases, and then leaving – giving a few people some surgical scars, but not much else. Here our goal was to teach new surgical technologies, and we certainly did leave ideas, surgical techniques, and most importantly, I do believe that we stimulated significant thoughts about the art of surgery to those with whom we had daily contact. Today’s one case might illustrate that best. We set out to do a lap gallbladder on a 73-year-old woman who I had not seen prior to her being induced for surgery. It was clear as well that the best two surgeons were also not well informed about her medical status. Suffice it to say that sometime after we started surgery, but luckily before we had taken any non-reversible steps, the patient began to have a series of alarming cardiac events, such that I immediately terminated the procedure. I think there was a lot of surprise at my decision, but it was clear to me that it was more important to have a live patient at the end of the procedure, than to have a gallbladder sitting in a bottle. That I could make such a decision so rapidly seemed to make a big impression on the staff as well as the two surgeons, that in the end, I realized that we had all learned far more than any of us expected when we set out. Stressing the need for a safe surgical approach, and helping the Mongolian staff to begin to achieve that, is truly a sustainable result of our trip, and in that regard, I think we might have accomplished far more than I expected. In addition, in part as a measure of their confidence in us, we were consulted late this afternoon about a patient with an incarcerated inguinal hernia, and it was very clear that they wanted us to help them with the procedure, which we did, and all turned out well. In a resource poor country such as Mongolia, the lack of physical items is only a small part of the whole picture. That the people themselves are willing to work hard, recognizing what they have to overcome, this to me seems to be the most positive aspect of the trip, and if I have played any small part in it, it does make all the discomforts well worth it to me.
We leave for UB in the morning, planning to visit the main Buddhist temple, to take warm showers, to have dinner at the same Indian restaurant where we met the first night, and to leave for Beijing on Thursday morning. I might write again before I return to the US on Saturday, but if I do not, please trust that my interest in doing a project such as this remains strong, and it is likely only to be circumstance that dictates where in the world that might be. Stay tuned.
From Khovd – 73’s