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. 

A trip to the orphanage

An interesting adventure we had during our pediatric week was a trip to a government run orphanage. This was a very bizzare, sad and awkward experience. It was bizzare because we were under the impression we were going there to do well child checks or immunizations, but instead, a consultant dropped us off and told us he'd be back for us in an hour. The 3 of us just looked at each other puzzled. What were we supposed to do?

A woman took us into the kid's room- one large room lined with row after row of cribs of crying infants and toddlers. We saw 2-week old infants up to a 15 year old with cerebral palsy. This poor child had not had any physical therapy or treatment for his CP and his extremities were so far deformed, he was no longer able to sit in a wheelchair or lay flat on a bed. When we saw the 3-4 year old's room, all the children were napping. I was surprised to see not one, but 2 children sleeping on each bed. There weren't enough beds for each child. There were no guard rails on these raised beds. Surprisingly, there was a HUGE play area that was donated by some Germans. This play area had thousands of balls and tunnels and areas to climb. It must have been 20 feet tall and put any McDonalds play area to shame. I guess this is where all the money is spent. Most children are under the age of 4 here and many are lucky enough to get adopted by Sri Lankans or foreigners (mostly German as we learned).

It was sad because many of the kids were crying or sick and had no one to care for them or console them. Many of the children here are a product of rape, or born to a young girl unable to afford a baby, abandoned at the hospital for no reason at all. One toddler had only been at the orphanage for 3 days. His mother couldn't afford to keep him and after 14 months, brought him to the orphanage. The child hadn't stopped crying since he arrived. I almost cried with him when I heard his story.

The awkward moment came when the lady asked if we saw any we liked and wanted to take home with us. Uhhhhh... I suddenly felt like I was shopping for a puppy in the mall. It was terrible. Just walking around, looking in each crib, giving hand shakes and playing peek-a-boo type games with the ones that could stand and grip the edge of their crib. It was awful. We didn't know what else to do. We weren't allowed to take them out of their cribs or go play with them or feed them or really assist in any way. I wish we could have helped out. With feeding, with bathing, play time, teaching, I don't know, but something...

We didn't know what else to do. We went into the office and chatted with the woman about the set up of the orphanage and how the government is structured to take the children and feed and educate them. Again she asked us if we liked any. It was sad to leave those kids there, and I'm ashamed to admit it, but I was somewhat relieved when our ride came back for us. I needed the sales pitch to end. I wanted to help, but I wasn't there to shop and buy and that's how these women made me feel. I truly wish there was more I could do for these kids.

Maternal Child Health Clinics

Since Sri Lanka is a public health system, it was really important for me to see how the clinics are run in the community. We were lucky enough to go to 2 different Maternal Child Health clinics (MCH clinic). Each MCH is run by the Medical Health Officer (and Public Health Midwives if it's an antenatal clinic). The first MCH clinic was a Muslim clinic where we saw antenatal checks and child immunizations. The child vaccination rate is up to 98% here in Sri Lanka. Impressive! No one over here is claiming autism or other ridiculous reasons for not vaccinating their children. They've eradicated polio (despite having India as their neighbor) and several other serious illnesses thanks to their vaccination programming and ease of the MCH vaccination clinics. 

In addition to the child vaccination clinics, we were able to go to an MCH clinic in Gintota, outside of Galle, to observe an antenatal day. Here, the Public Health Midwives run the show with an OBG consultant either on call or present at the clinic. The Public Health Midwives are trained much like our Nurse Midwives, though they rarely do deliveries outside the hospital unless the mother cannot make it to the hospital in time. Sri Lanka has a 96% institutional delivery rate, a vast improvement thanks to several government educational outreaches. With the increased hospital deliveries has also come a drastically decreased maternal mortality rate. In basic language: Sri Lankan women are now being educated on prenatal and postnatal care and getting themselves to a hospital for a safer delivery. 

MCH Clinic in Gintota
Antenatal clinic day

Paperwork with measurements, education checklist, vaccinations and other checkpoints for  all pregnant mothers. Completed by the Public Health Midwife. The PHM and patient each keep a copy and have to bring to each visit. 

Patients entering the clinic and waiting to register. 

After registration, a nurse documents their vitals. 

At the MCH appointments, the midwives are responsible for tracking fetal heart tones and measuring the fetus' growth. There are no dopplers or ultrasounds however, so they use a pinnar (like an ear trumpet). This plastic funnel looking instrument is pressed into the mother's abdomen after performing Leopold's for the fetal positioning and finding the shoulder. I had a really hard time hearing the fetal heart rate (which sounds the same as through a doppler), but after a few tried, I was able to properly line up my ear canal with the open tube of the pinnar and hear the sounds! Success! We are so reliant on technology in the US it's sad. What a simple and low-cost way of hearing the fetal heart tones. I'm glad I was able to acquire this skill. 

Patients lined up outside the exam room.
Waiting to be seen by the Midwife.

Public Health Midwife measuring the fundal height. 

Public Health Midwife using a pinar to hear  the fetal heart tone. 

Pediatrics at Karapitiya Hospital

In our second week at Karapitiya Hospital we were able to do inpatient pediatric medicine. The pediatrics (peds) ward is a much different experience than our adult medicine week. Here, there are several consultants that round on the ward, so the medical students and house officers are divided up into much smaller groups. For me, this was such a great experience because I got to round with Professor (Dr.) Jayantha who LOVES to teach. He was so wonderful in making us feel included as learners, spoke only in English- except to the patients of course- and PIMP'ed us just as hard (if not more so) as his students. For my non-medicine followers, PIMP stands for 'put in my place' and it's a method of teaching where the teacher (in this case Consultant) asks the student questions one after another basically until you feel like a total moron and can't answer any more or they're satisfied with your responses. Then you have to go look up whatever you didn't know and report back. Anyways, I learned so much from my few days on the peds ward- I'm getting better at reading chest x-rays, deducing what type of bacteria may be to blame based on physical exam and radiography, and how to do a proper neuro exam on a patient with cerebral palsy.

From left: Senior Registrar, Mollie, Me,
Professor (Consultant) Amarasena, Holly

One day we did rounds with Professor Amarasena who is also a fantastic and enthusiastic consultant and teacher. During rounds he asked me to inspect a child and examine him. All I knew about the child was he was there for a broken arm. It seemed strange that a child was admitted for that, so I figured something else was up. Dr. Amarasena specifically asked me to inspect and palpate the child's head. When I did so, I noticed that this 2+ year old child still had an open fontanelle. This should have been closed by now, so there was clearly something besides a broken bone going on. Prof Amarasena looked at all of us students and told us to write down 3 differential diagnoses for this patient. He then looked over at the 3 of us sweaty monsters dripping in our white coats and said, "You too. Write down 3 diagnoses and then we go snowboarding!" Huh? Holly and I looked at each other and our eyes both said 'did he just say snowboarding'? He laughed and said, "yes, we go snowboarding." Holly replied with "I'm good with that!" We were a little embarrassed that we were sweating so much. How is it that none of these people were sweating? They never sweat! They never drink water; they never pee; they never sweat! How is this possible? Anyways, we got back to inspecting the child for our differentials. I then noticed that the child had blue sclera (or maybe I was making myself see blue sclera because I had a pretty good idea what this kid had) and immediately my differential included osteogenesis imperfecta (OI). Luckily, I had done research on OI when I worked at Children's Hospital in Boston so when he started to pimp us on OI I was able to answer all his questions.  

Pediatric Ward

The hallway outside of the busy renal clinic.
The waiting room was stuffed full.

One disorder that I noticed commonly on the peds ward was nephrotic syndrome. This is much less common in the States and it was a great opportunity for me to learn something new. Professor Jayantha brought us to his renal clinic where we saw many babies and young children with pyelonephritis, UTI's and nephrotic syndrome relapses. The clinics here are jam packed with people lining up and down the hall due to an overstuffed waiting room. Once the patient's name is called, they are brought to our room. A basic exam room with no bed, no supplies, just a typical-sized doctor's office room with a dining table and chairs. There are 3 physicians seated at the table with 3 chairs by their side, ready to be filled by 3 patients. There are also 7 or so of us students and 2 nurses in the room....nice and cozy huh? I've been slowly getting accustomed to the heat and humidity of Sri Lanka, but wearing my heavy white coat and standing still in a room this crowded without circulation....this was the closest I had come to passing out during my training. I was literally touching shoulders with both Mollie and Holly and my back against the wall and half a foot away from the patient sitting in front of me. But, aside from the gray-screen that started appearing in front of my eyes, I did learn a lot about nephrotic syndrome and the various types- something I had know nothing about before. Prof Jayantha is very passionate about this subject as it is also his area of focus for his research. I'm not sure if it's Prof Jayantha's teaching or what, but I might consider pediatrics after all....

Saying that out loud (or writing it to you all) makes me laugh. It makes me think about how scared I was of doing well child checks during my primary care rotation. It seemed like such a big job to make sure you remember all the important educational points to discuss with the parents and to do an exam on a kid without making them cry, well that's a skill I didn't think I had in me. After doing my first few pediatric appointments and well child checks, my preceptor, John Sallstrom, asked me if I was sure that I didn't want to go into peds. Flattered, I laughed and said, no. But John, you may have been on to something!!! I think I'm digging this pediatric thing after all. Guess this is why we do rotations in every major area before we apply for jobs!

Pinnwalla Elephant Orphanage

We took off from Madawadamulla this morning before sunrise, though we knew the sun would be rising any minute since the steady chanting from the Buddhist temple had begun. Even at this early hour we had to dodge stray dogs, cattle, goats, and birds in addition to the motorbikes, bicycles, buses and tuk tuks. Pretty sure my driver was preparing for a NASCAR race with the way we were speeding around the windy mountain roads of the Hill Country. Passing vehicles around blind curves, our driver slammed on his brakes so often I thought my breakfast was going to come up. There were several very close calls where we were within inches of losing our lives- I know this because I saw my life flash before my eyes about 6 times.

When we arrived in Pinnwalla, it was clear that the town's entire economy revolved around the elephants and tourism. There were beggars waiting next to our minivan ready to harass us. I looked down the road to where the elephants were bathing in the river and saw a row of tourist shops selling souvenirs and knick knacks. "Madame, which kind of magnet do you like? Please come in my shop. Have a look." My favorite lady was selling "handmade" hobo bags with elephant print fabric---ironically identical to the ones I saw all over beach towns in Thailand. Maybe she hand made all of those too... I could tell this wasn't going to be the "orphanage" that was described in the travel books where they talked about rescuing the wounded and orphaned elephants from the civil wars. Further describing how many of these elephants had a leg blown off from stepping on landmines.

Well, I saw no three legged elephants and the only injuries I noted were from the chaffing of the metal chain the elephants wore around their ankle. These elephants were on house arrest. It was heartbreaking. This place was a sham and they should really reconsider naming the place an elephant farm since they're also breeding baby elephants for their 1:00 Baby Elephant Bottle Feeding show. I'm really glad I got to see elephants being treated so well and living freely in Thailand. There it was clear these animals were like family members to the mahouts. Here, these people used spears to poke and stab the elephant into doing what they wanted. It reminded me of the ring leader in the book "Water for Elephants."

We were taking pics and poor Mollie and Holly were totally scammed by the trainers- they were told they could pet the elephants and he's take pictures. That had trouble written all over it. They each pet an elephant and posed for a picture and before giving their cameras back, they demanded a tip. Not only did they say, "tip Madame" as a command, but then told them it was 500 rupees ($4.91). Holly's 'photographer' said he took good pictures for her. When we looked back, he didn't get any with her looking at the camera or without other tourists all over the picture. It's a good thing I was taking her pic with my camera too. I didn't even charge her a 500 Rupee tip.

At least I caught Holly looking at my camera!
Notice the stabbing spear in the guy's hands.

We didn't even stick around for the "main attraction" of the bottle feeding. We couldn't handle any more beggars or folks shoving bananas in our face to feed the elephants (which they were demanding 100 rupees/ banana AFTER people fed it to the elephant.) Terrible. Time to hit the road!

But I did take a zillion pics of the elephants because I just loved them and wanted to take them all home with me... well, take them all away from this place at least.

Leijay Resort- Our Sri Lankan home

Our home for the month. 

For our month long stay in Sri Lanka, we stayed at the Leijay Resort in Galle. We were about a 10 min tuk tuk ride from the Galle Fort, 15 min from Unawatuna Beach and only 5 minutes from Karapitiya Hospital. The resort was more like a guesthouse in that there were just two homes with 2 rental rooms in each. There was a flat in between the two homes that could also sleep 4 people. Each home had a shared patio, common room and kitchen, though we didn't need the kitchen since we had Jayantha! Jayantha is the chef on the property (and pretty much ran the whole place from behind the scenes) and he made some of the best food! He could make anything from the standard rice and curry to chicken piccata. It was nice to have the option of eating western food if we needed a break from all the curry. Mollie and I barged in the kitchen one afternoon while he was making our curries for the evening- we wanted to learn to make curry so we could fix it ourselves when we go into withdrawal in the US. He laughed at us but let us stay to watch. We saw him make dahl (lentils and coconut milk), a chicken curry, and 2 different vegetable curries. YUM! It seems simple, but probably because Jayantha's been cooking for a long time. I hope I can figure this out when I get back!

Rock climbing is easier than coconut-tree climbing!
I don't have monkey feet! 

The staff at Leijay was fantastic. Dinesh- our tuk tuk driver- was a man of many talents. If we needed money exchanged "I do that. No problem." If we needed a ride to the beach or to dinner,  "I do that. No problem." If we wanted a coconut to drink while lounging at the pool.... he and his monkey feet would climb up. No problem. One afternoon I tried to climb the trees myself, but apparently it's not like rock climbing. I could hang on to the tree for a while, but there was no vertical movement. I couldn't get my hands and feet coordinated to move while shifting my body weight. It seems easy. Trust me, it's not. Luckily, after Dinesh watched and laughed at me for a while, he decided to show off and climb a higher tree to get each of us a coconut to drink. The King Coconuts (yellow) are much different than the coconuts I'm used to... the green ones you see in Hawaii. The kings are yellow and have a sweet water inside. Yummy!

Having grown up in Unawatuna, Dinesh knows all the hot spots for us to go to.... bars, restaurants, beaches, you name it, he's got a suggestion for us. And he was never wrong! Everything he suggested was incredible. Best sunsets, delicious food, great parties, good times!

Dinesh is the pro tree climber. He went to get me a coconut.

Dinesh opening up a King Coconut for me!

Dinesh let me drive the tuk tuk! Only for a few minutes
and only on our small street, but still. I drove it! 

The grounds keepers and house keepers were also so sweet and always smiling. Seriously, always smiling. There was no way you could look at Maleni and not feel good. Her joy was infectious. The Swiss owner, Yvonne, also lives on the grounds and really does treat us like family. When my classmate Holly was sick and coughing, Yvonne brought over her personal cough syrup (Syrup Maduka- some crazy molasses-smelling Ayeurvedic stuff), sent the boys out to get her some other medicine, got her some tea and offered to set her up at an clinic if needed. She really wanted to make sure we were happy with our stay. The hospitality here was incredible.

Our lizard friend! 

Yvonne is also a huge lover of animals and has taken in 4 stray dogs on the property. There are many wild dogs roaming around Sri Lanka. It breaks my heart to see so many of them with bites out of their ears, or patches of fun missing from being burned or tortured by evil humans. One of the dogs, Cherie, was rescued after some boys tried to hang her from a tree... just for fun. So much for that Buddhism they claimed to practice. Needless to say, Cherie was very frightful of people and only trusted Maleni or Yvonne (probably cause they fed her!). Balu (means dog in Sinhalese) is one of the dogs who took a while to warm up to us. He always watched us from afar, not venturing onto our patio, but watching his buddy Dutchess get all our love and attention. By the last week of our stay Balu was making his way onto our patio for belly rubs. He wasn't going to let Dutchess get all our loving!

Overall a great place to stay. It really was like a home away from home. It was easy to hop on the bus (a whole other blog posting!) or have Dinesh take us on the tuk tuk anywhere we wanted to go. Any tour we wanted, they would arrange it. Any beach we wanted, they would take us. Any food we wanted, Jayantha would cook it and if he couldn't cook it, they would go out and get us take away! We couldn't have asked for a better home for our month in Sri Lanka.

Dutchess

Balu

Update

Hi everyone!

I just wanted to let you know that I've updated the previous Thailand blogs with pictures so feel free to flip back through and check them out. Also, I will be posting all my blogs from Sri Lanka now that I have internet access again! I have over 1200 pictures to sort through so bare with me as I post them over the next few days.

I know the email following has stopped working so many of you haven't received an email since my Christmas blog. I'm sorry but I have no idea how to fix this. I'm tech challenged. So as I continue to post my Sri Lanka blogs, you'll just have to go to http://tracysinternationaladventures.blogspot.com/

Check back again this week!

Istuti (Thank you in Sinhalese)