Tales from the OR

Yesterday I spent the morning at St. Paul’s in the OR with the general surgery residents. One of them, named Brihan which means “light” in Amharic, was kind enough to take me under his wing. Of course this meant he took me on as his medical student and pimped me throughout the case but that’s ok. For those of you non medical students, “pimping” refers to when residents and attendings ask you questions on rounds or during an operation to test your knowledge and get you thinking and is nicely coupled with anxiety and pressure. Think the Socrates method of learning.

I have noticed that everyone hear focuses a lot on the meaning of names. Most names have some sort of underlying definition in Amharic. People are also very curious to know what your name means. It’s kind of hard to explain that your parents just liked the name “Katherine” and that it doesn’t really mean anything, so I go with that it’s a biblical name. People seem to be okay with that. They do get a kick out of “Tennis” though. Another interesting thing about names here is that no one has a surname. Their last name is their father’s first name. So Dr. Engeda Abebe is the son of Abebe, and his son will be named something Engeda. It makes it kind of hard to figure out who is related to whom!

Ok back to the OR—after I changed in the “locker rooms” I went to check the OR schedule which is written on a piece of paper pasted on the hallway wall and hunt down a scrub cap and mask. The locker rooms are divided for surgeons and nurses not by gender, which makes it quite interesting. For a culture so concerned with modesty, it was a little shocking to see a female attending start taking off her clothing in front of all the other male attendings. No one else seemed to care so I just went with it. 

Our first case was an open cholecystectomy for cholelithiasis (gallbladder removal for gallstones).  I headed with Brihan to go scrub in. The OR suites are arranged as three rooms off of a central “core.” Like I said before there really is no observation of US sterilization techniques. Patients kind of hang out in the core on black stretchers, semi reminiscent of a morgue actually, and all the OR room doors are kept wide open so anyone can wander in and out. You don’t have to wear a mask unless you are actually involved with the operation and even then, they only wear masks over their mouths and don’t cover their noses. Scrubbing in involves semi vigorous hand washing with regular soap. Once your hands are clean, you head to a little room next to the sinks where they have bundles of gowns and towels wrapped up in sheets tied with string. Usually one of these bundles is left open on a table (read not sterile) so you can grab a towel to dry your hands and a gown. The gowns are folded a new way each time so it’s kind of impossible to make sure the “sterile” part doesn’t touch you. In the US, this is all done by the scrub tech and is kept very, very sterile. Once gowned, you hunt down gloves and try to put them on without contaminating them or yourself. They only had size eight gloves and I am a size six so it was a little interesting. As I was clearly struggling to get suited up one of the residents asked me if this was my first time gowning and gloving. I tried to explain in the most PC way possible that we do things differently in the states but I’m pretty sure he just figured I was incompetent.

Then it was off to the OR! The patient lies on a black stretcher with no sheets and no one really talks to them. Their blood pressure is monitored by a manual cuff once before the operation and once after, and no one uses a stethoscope to check tube placement or if they are breathing ok. The only thing they have is a heart monitor. Once under, the operation gets started really quickly. There is not much time spent draping, cleaning the patient, and there is no call to order.

We started with a transverse approach and then were stalled by the fact that the bovie didn’t work. It took about 10min with the patient open in a non-sterile environment to find one that did. We dissected through the tissue and visualized the gallbladder. The main difference I noticed at this point was that these surgeons didn’t take their time to dissect thoroughly, visualize the anatomy, or practice good tissue handling. Honestly, I don’t think any of that was due to their ability as surgeons. They are working with old tools that are bulky and hard to handle (although they have definitely mastered how to use dull scissors) and I’m sure they try to reduce how long the patient is under as much as possible. The gallbladder was removed fairly quickly, though I was pretty terrified that they were cutting the common bile duct but what do I know, with only a minor spillage of bile into the peritoneal cavity…Then we worked on closing and they let me cut some suture and close the subcutaneous tissue. They thought I was ridiculous because I could not for the life of me work the stupid dull scissors and I realized how nice we have it back in the OR’s at Emory.

The next case was a right total and left partial thyroidectomy on a 65 year old woman who had a physiological goiter due to an iodine deficiency. She was from the highlands of Ethiopia where they have a huge iodine deficiency causing the thyroid to have to work overtime to make enough hormone. Her neck looked like she had swallowed a softball. Normally in the US you never do a partial thyroidectomy but in Addis, they don’t have enough money to place a patient on Synthroid for life so they have to leave a part of the thyroid in the patient. This operation would normally take 3-4 hours in the US (depending on the surgeon, you Emory B people know what I’m talking about!), but we did it in 1.5 hours. This was mostly because we never once looked for the recurrent laryngeal nerve or the parathyroid glands, and we didn’t identify each artery supplying the thyroid gland. We merely sectioned off chunks of tissue attaching itself to the gland and ligated it en mass.  For this operation, Brihan let me close. We actually closed the skin with subcuticular suturing which was surprising. I figured we’d do interrupted stitches due to lack of suture. It was a little difficult to suture using giant forceps as pickups but I somehow managed. As I was closing, all of these medical students started hovering around me, commenting on my technique. It was ridiculously awkward. Considering I haven’t sutured anything in a good three months, I was pretty rusty, and struggled a bit to find my rhythm. I was a little surprised I was allowed to due anything at all, but was grateful for the opportunity, even if it was slightly embarrassing.

Today I am taking a breather and relaxing at my Farenji mecca. It’s beginning to cool down here and the rainy season is settling in. It took me 2 hours to get home yesterday by mini bus with a good 30min of it spent hovering under my small umbrella with an Ethiopian woman as we waiting for a bus to Bole. When they are infrequent like yesterday, you have to charge the bus and push your way on, so my new Ethiopian friend and I had to become a dynamic force to secure our seats!

Tomorrow I am hoping for more OR time and more observing. There is always more to learn!