Surgery at Karapitiya

Finally! Surgery week!
Wooohoooooo!

Operating table. No fancy tilt motions here, just up and down. 

In my third week at Karapitiya Hospital I was introduced to Dr. Kumara, senior lecturer in Surgery. Participating in various surgical cases was what I was most looking forward to on my rotation in Sri Lanka. The first thing out of Dr. Kumara’s mouth was, “You’re from the USA? You know Mrs. Obama?” I laughed and said, “No sir, I don’t.” He immediately moved on to his next line of questioning, asking why I chose Sri Lanka of all countries. I proceeded to explain my interest in global health and disaster relief. He cut me off and said, “But there’s no natural disaster right now.” A grin formed across his face and he continued, “Just our whole country’s a disaster!!!” With that introduction we were handed our scrubs and taken to the operating theater.

Changing into some damp scrubs in a small closet.
The white shoes on the floor are the required OT shoes
that we wear instead of booties over our own shoes. 

Walking into the operating theater I noticed it was quite a different set up from the operating rooms back in the states. And it’s  a good thing I had a surgical mask on to cover my mouth because my jaw definitely dropped! Patients were lined up right outside of the open theater doors with their medical chart in hand. Some patients were even curious enough to stand and watch the ongoing procedures from the doorway. On the other side of the patient bench was a make-shift PACU where the post-operative patients were still coming out of their anesthesia. Inside the operating theater, there were multiple procedures going on at the same time. In one corner of the room, a woman was having a lumpectomy under local anesthesia. In the center of the room, a man was under general anesthesia having an open cholecystectomy. Finally, off to the side of the room a woman was getting a carpal tunnel release.

You can see two of the operations going on in the room.
Far patient is lumpectomy, close patient is getting started
with  general for an open cholecystectomy.

As I was taking in the similarities and differences of the operating rooms, one of the general surgeons asked me to scrub for a thyroidectomy. As I got ready to scrub, I noticed there were size 6 or 8 gloves. I’m a 6 ½ so my choices were too tight or too loose. Thankfully my hands managed with a size 6. Anyways, the case got underway and I was impressed by the speed and precision of the surgeon. Thyroidectomies are a very common procedure here in Sri Lanka and these surgeons perform so many each day, I'm sure they could do this procedure in their sleep. A short time later, we were done and ready for the next patient. The turnover time between cases is quite rapid. Turning over an OR at home takes a bit of time, but here, there is no time to waste. They have so many patients in need of surgery and not enough resources to do so. 

One thing I found truly amazing about the Sri Lankans is their strength to overcome adversity. But more impressive is the way they do so without complaint. The patients waiting in the hallway of the theater could be there all day long, sometimes not having their surgery until 1 in the morning, but there was no complaining. I commented to one of the orthopaedic surgeons about how refreshing it was to have people be thankful for the help they are receiving instead of complaining about the wait time, or cosmesis, or post-op pain, or even the food at the hospital! The surgeon told me that Sri Lankas are very accepting of their own problems and illnesses. Then he smiled, leaned in and said, "Sri Lankans don't sue their physicians and that's something you all have to worry about over there." Sri Lankans understand that this is the life they were given and they will deal with it as best as they can. No ambulance chasing or frivolous lawsuits here! Must be nice...

Assisting on a thyroidectomy.
Notice how I'm the only one wearing a mask over both my nose and mouth?

After a few ortho surgeries, I stepped into the general surgery suite to watch an open cholecystectomy. Since we do these procedures laparoscopically, it was a new operation to me. There is only one scope for the entire hospital so most all procedures that we would do laparoscopically at home are performed as an open procedure here.

Similarly, the hospital does not have mesh implants for hernia repairs. Instead, I learned an old suturing technique to weave a meshwork of suture over the opening. Quite impressive and cost effective. As a global practitioner, I’ll need to be prepared to assist in surgeries with fewer resources and embrace both old and new techniques to achieve good end results. I am very grateful to have watched so many procedures and techniques that I won’t get to see (or rarely see) in my training in the US. 

I also spent time with Dr. Kumara during his thyroid, vascular, and endoscopic clinics. In the thyroid and vascular clinics I was surprised to see patients bring their own injections to Dr. Kumara. I have been in peripheral vascular clinics and seen the sclerosing process, but I had never seen a steroid injection delivered right into a goiter. Once again, these Sri Lankans showed impressive strength and not one of them flinched or grimaced at the needle in their throat. I’m pretty sure I would have cried. In the endoscopy clinic, I was was stunned to see that patients were not sedated for upper endoscopies or colonoscopies! But once again, there are no resources available to take care of these patients post-procedure if they were to have an anesthetic. So using a local anesthetic gel on the probe is the only feasible option. Again, not sure I would have been so brave.

I'm not sure I want to share this next story, but since I'm putting it all out there, I may as well. In the middle of the thyroid clinic, Dr. Kumara looked up at me and shouted, "You're going to live to be a hundred!!!" He was so excited I had to laugh and ask why he knew that. Without hesitation he told me it's because I have 5 wrinkles. Great. Awesome. Fantastic. I'm an old hag. I told him that I was trying to get rid of those!!! He shouted "NO! Keep them! You must keep them!" He was serious. And I'm not sure I have a choice in the matter, so I guess I'm keeping my 5 wrinkles, which apparently count for 20 years a piece and I'm destined to live to 100. Longevity does run in my family. I guess I can't take offense to this comment because just moments before he had guessed that I was 23 or 24 years old. Close Dr. K, close. After note to this story- I bought a Sandalwood Oil thingy from an Ayeurvedic herb garden that we went to that next weekend. Apparently mixing sandalwood oil with Vitamin E or aloe and putting it on your face 2x week will get rid of wrinkles (or cellulite or scars, etc). Yep, it scarred me.

This was the wrinkle day.  Can you see the 5 in this close up?

Back to western medicine. When we completed clinic, Dr. Kumara looked at my colleagues and I and said, “WWII is over, you can go talk to the Germans now!” Funny man. Loved him. We got along splendidly. So with that proclamation, we headed to another operating theater where they were having casualty day and met up with two German medical students, also doing an elective rotation. We spent the rest of our day in the casualty theater assisting in I&D’s, suturing small lacerations and bandaging head wounds. Overall, surgery in Sri Lanka very much surprised me. For the limited resources available, the shortage of qualified surgeons and the ever increasing number of patients in need of surgery, the surgeons here are very efficient with their time, skilled in technique and resourceful. We may have different ways of carrying out a procedure, but we all get the job done.

Open cholecystectomy

Looking into the "sterile core" on the left. Sutures, gloves (size 6 or 8 only), other random things you may need during surgery straight ahead.