Neurosurgery at Rafidia Surgical Hospital, Nablus

I had all day Friday and Saturday morning to rest up from my overnight flight from Bangkok to Tel Aviv. We saw a few patients on Saturday afternoon. One touching story was that of a 23 month-old girl with a condition called a "tethered cord". As her spine grew it put tension on her spinal cord, that would result in damage to the lower spinal nerves. This would impair her ability to walk and control urinary and bowel activity. The more serious problem was her congenital heart disease. Her heart defect caused diversion of blood from her lungs and was not correctable. Her lips and nail beds were blue, her breathing was labored and she was febrile. Her parents were well educated. I explained to them that the risks of anesthesia and surgery for their child were very high, with a great chance that the baby would die. Despite that, the parents were adamant that they wanted surgery and offered to sign any document necessary to absolve us of responsibility. After discussion between the members of the team we decided not to proceed with surgery. The baby had very little if anything to gain and her likely outcome would reflect badly on the foreign surgical team. She was admitted to the hospital with pneumonia and passed away two or three weeks later.

Two other patients were more rewarding. The first boy came in on Saturday. He was a 16 month old child with multiple intracranial cysts that caused hydrocephalus. He'd had shunts placed in the past, but they failed because of positioning or infection. His father cared for the baby at home, draining the boy's head with a needle and syringe. When his father brought the boy in the baby wasn't feeding and had "sunset eyes", downward-deviated gaze that comes with increased intracranial pressure.

 One of the surgeons drained some fluid from the baby's head and we put him on the schedule for the next day. The anesthesia presented a challenge because of the size and shape of his head, but by putting a pack of towels beneath his shoulders I got him into a position where he could be intubated.

Despite the drainage procedure the baby's intracranial pressure was quite high at the time of surgery, as shown below by the flow of cerebrospinal fluid from the new shunt.

The new shunt was working well two days after surgery. The baby's gaze was more normal and he was feeding vigorously.

The child's days are numbered because of the pre-existent brain damage, but he won't have to have painful drainage procedures performed by his father.

The second case was a seventeen day-old child who came in with sunset eyes and a decreased level of consciousness. The baby's fontanelles were tense. The more alarming finding (to me) was his heart rate: mid-70s. This is distinctly abnormal (slow) for a child his age. We had the baby admitted to hospital for surgery later that afternoon. When I called for the patient to be brought to surgery, I got a note saying that they were unable to start an IV or draw blood for the battery of lab tests the admitting doctors ordered. I asked the staff to bring the child to the operating room, saying that we would take care of those problems down there. When the child arrived he was lethargic, with a heart rate of 80. His hands and feet were mottled with a capillary refill time greater than 6 seconds. His poor circulation explained the difficulty with an IV. I gave the child some intramuscular atropine, did an inhalational induction, intubated him and tried to get an IV. After about forty minutes I got a cannula in a scalp vein. Not my first choice of a  site for a shunt, but I was not in a position to be choosy. I had a Palestinian first-year anesthesia resident helping me. When my back was turned the young doctor adjusted the child's head managing to remove the IV and extubate the patient. I was disappointed, but we got him intubated and another IV started. The shunt placement went well. Three hours later his heart rate had climbed to 130, a more appropriate value. His extremities were better perfused. The next day the NICU nurses were able to start a better IV, and two days later he was nursing every three hours. In the photo, you can see the shunt coming out from his skull, traveling behind his ear and continuing down his chest and onto his abdomen. Not much subcutaneous fat on this child.

This last photo is interesting because of the mallet. The surgeons are using a mallet to drive in screws that will hold the plate in place over the skull defect. Why use a hammer to place a screw? The plate and screws are made by the Synthes company, and you need a Synthes screwdrive to twist in a Synthes   screw. Unless Israeli customs confiscates your Synthes screwdriver at the airport. Then you use a mallet.

A Day or so of Travel: Mandalay-Bangkok-Tel Aviv-Nablus

We took a twin-engine turboprop airplane from Mandalay to Yangon. The flight was very smooth and an advantage of the slower aircraft over a jet is that it didn't climb so high or so fast. Here is a view of central Burma, referred to as the dry zone. They receive less than 39 inches of rain per year, and most of that falls during the monsoon. We visited a couple of weeks before the rains usually begin, which explains the sere appearance of the landscape.

As the trip progressed we gained altitude and could see a range of hills below us and a more impressive mountain range in the background.

Looking back, I think the trip to Burma was good for several reasons. I enjoyed learning more about Buddhism. I learned how the concept of karma could transform a society. I got a chance to rest up before heading off to the pediatric neurosurgery rotation in Palestine. I saved 14 000 miles of air travel (compared with returning to USA and then making a round trip to Palestine.

This is a replica of one of the demon warrior statues found at the temple of the Emerald Buddha in Bangkok. There are twelve, and they are meant to protect men from evil spirits. The statues were initially placed in the arrival hall. This led to staff complaints that they were bringing bad luck to the facility, and the statues were removed to the international departure area. My only bad luck was an inability to stay on line with Boingo for more than three minutes at a time. We left Mandaly about 0900, arrived in Yangon at 1000, left for Bangkok at 1430. I had dinner with Chaiyan Kasorndorkbua, a veterinary pathologist and outstanding birder I met in Ames while he was in graduate school. After dinner I had a great opportunity to look over the airport before my Royal Jordanian flight (not Air Jordan, as I erroneously described it to one of my mates in Udon Thani) at 0030.

After twelve or so hours in the air and a refreshing fifty-five minute layover in Amman (that included a trip through immigration and security) I rolled in to Ben Gurion airport in Tel Aviv. The immigration and customs people were very pleasant. I waited for a bit for my ride. We made contact and he offered to get me a coffee before we left for Nablus. While he was at the coffee stand a nice man from airport security came up, wondering if the driver had given me anything (or done anything that might justify, like he needed a reason...oh, never mind). We sorted that out amicably and I was on my way to Nablus, a city in the west bank between Jerusalem and Nazareth. We rolled up to the Al Yasmeen hotel, famous for its reception area. In the winter you can see your breath. I checked in, had a bit of breakfast, took a shower and hit the rack.

Mandalay: A Temple, Lots of Gold, and Factories

 I've written about Buddhist piety and the belief that laudable works will improve one's karma. Birds, an interest of mine, have a role in the karma business. Vendors capture wild birds (incurring bad karma) and offer the passer-by a chance to release them, for a price. I turned loose a barn owl and a small accipiter that I didn't recognize. So I got to   examine a couple of raptors in the hand and ramp up my karma in the bargain. The freed birds didn't fly very far (the owl landed in a cornfield, the accipiter flew into a nearby woods) and I have a feeling they were recaptured later that day.

Devotion to the Mahamuni Buddha took a form more familiar to me. This statue is found in a temple in Mandalay. The statue was put in place around the turn of the nineteenth century and has become the object of extravagant devotion. The photo shows a young man applying gold leaf to the statue. The statue reminded me of a Christmas tree decorated by pre-schoolers, with heavy ornamentation as high as the people can reach.

These photos show the progression of the decoration of the statue. The fingers of the Buddha's right hand are now fused (see above) as the spaces between filled with gold. Six tons of gold is the estimate of the mass of the adornment, doubling the original weight of the statue.

This photo shows devotees applying gold leaf to the left leg and arm of the statue. Based on their dress I'd say they are middle class guys (women aren't allowed to approach the statue). I think the gold is donated anonymously. I don't see how you could put your name onto the leaf, especially if another person comes along five minutes later and covers it.

This lady is at work in a laquer factory. She is washing the gold leaf from the box. Gold stays where a fixant has been applied. Her accessory thumb is not slowing her down! The gold in the wash water is recovered at the end of the day.

This lady is spinning silk fiber into thread.

Here a man is at work on a manually powered loom, weaving silk threads into fabric.

Burma: Two Days in Bagan

The Bagan area was the center of the Kingdom of Pagan, the first politic entity to include the territory

of the modern Myanmar state. The area saw construction of over 2000 temples and stupas (structures that don't have an interior place for prayer), most of them in the eleventh through thirteenth centuries. According to Wikipedia the burden of tax-exempt religious property weakened the Pagan state to the extent that it fell to invaders in 1297. Keep in mind that these invaders were the Mongols, who ate the lunch of everyone in Asia and eastern Europe, so it might be unfair to blame Pagan's fall on excess temple property.

 I think the temples are making up some of the damage, attracting tourists to the region. There are some luxurious hotels in the area. This one is owned by a relative of one of the junta that ruled Myanmar until a few years ago. For $300 US you can get up early and take a hot air balloon ride at dawn to view the temples. I chose to save my money, sleep in for a bit and take this picture from the terrace of our hotel.

We did more touristy type things in Bagan than during the rest of the tour. One afternoon we went on a short cruise on the Irawaddy River, the Road to Mandalay that connects the interior of Myanmar to the Andaman Sea. The short cruise concluded with a somewhat longer cocktail hour on the beach. This is the best sunset I saw in southeast Asia.

The Shwezigon Pagoda is one of the oldest in the area. It's central bell-shaped stupa, shown above, is covered in gold leaf. It is the a major tourist attraction in the city of Nyaung-U, the capital of the modern district that includes Bagan.

Myanmar does not offer free public education. The temples offer some schooling for boys whose families are unable to pay. Myanmar boys are expected to spend some time in a monastery, wearing the robes and following the monastic routine. Most don't stay on for more than a few weeks. These boys are holding begging bowls. I had it explained to me that the monks do not beg; they merely make it possible for the pious laity to offer donations.

Burma: A little more on Yangon

 I think labor must be pretty reasonable in Yangon. This is a close-up of scaffolding near the Shwedagon temple. It must have taken quite a while to assemble and I think the third story might be a little shaky.

 The red splotches on the sidewalk are betel juice (apologies to Michael Keaton). You cut the nut into chunks, add a little lime (the mineral, not the fruit) to improve alkaloid absorption, and wrap the mixture in a fresh tobacco leaf. The juice will stain your teeth red, but not to worry: they will soon fall out due to gum disease.

This is a statue of a man riding a galon, a mythical bird astrologically associated with people born on Sunday. That's me! I think it looks like a bird equivalent of a centaur.

We visited the only synagogue in Yangon, probably the only synagogue in Burma. It's a Sephardic congregation, possibly descended from Jews who stayed on in Babylon after the restoration of the temple. Their Torah, seen here, is 125 years old.

The Reclining Buddha at Chaukhtatgyi Temple is not the largest in Burma, but certainly large enough. I think this image of the Buddha commemorates a confrontation he had with a giant who, after seeing just how big Buddha could become, learned a little humility. Also, the reclining posture is associated with the beginning of the passage into Nirvana. I am a big fan of the axillary roll, placed to prevent traction on the brachial plexus and ulnar nerve injury.

 Buddha is not wearing his big sandals here, so we can appreciate the 108 auspicious symbols by which the Buddha can be recognized. I was fascinated by the amount of information that is stored in the Buddha's footprint. Some people have devoted years to the study of these symbols.

Burma: Shwedagon Pagoda in Yangon

Buddhism is to Burma as politics is to Washington, DC. Except in Burma everyone 

is running for office. There are some spectacular displays of piety, fantastic amounts 

of wealth devoted to adorning statues of the Buddha in an effort to achieve good karma.

The country is coming out from under a decades-long rule by a military junta. There are 

beautiful, luxurious hotels (some owned by the relatives of the generals) less than a 

kilometer from people living in fairly desperate circumstances. 

I had four free days between finishing the mission in Thailand and starting a gig in Palestine 

with a different group of people. I spent the time touring Burmas with group of people from

the Thailand mission. We visited two cities and one rural area that was peppered with

pagodas. Lots of statues, lots of history. I am very curious to see what Burma will be 

like in twenty years. I am very happy that I had the chance to visit in 2013.

Sacred Fig, Shwedagon Pagoda.
Prince Siddhartha left his
palace at the age of 29,
renouncing his possessions to search for enlightenment.
After many hardships, at the
age of 35, he achieved
enlightenment while meditating
beneath a sacred fig tree, Ficus religiosa. This statue of the Buddha, found on the SE corner of the upper terrace, is sheltered by a F. religiosa thought to be a descendant of the tree that sheltered the Buddha.

The Shwedagon Pagoda is thought to be the holiest site in Burma. Tons of gold, in the form of gold leaf and gold plate applied to the bricks that form the towers, have been used in its decoration. This tradition dates back to the fifteenth century, when Queen Shinsawbu donated her weight in gold to the pagoda.

One of the qualities I found endearing was that the Buddhists don't take it all too seriously. Above is what is called the  "TV Buddha". This statue is thought to be associated with success in politics. The military junta that ruled Burma didn't want anyone other than themselves to be successful in politics, so pilgrims are not allowed to pray before the statue itself, only this closed-circuit image. And it's not even HD!

More on Udon Thani

Those who know me won't be surprised to hear that I've been a slug about keeping up the blog. The mission in Udon Thani was extremely well organized. One of our sponsors was Bangkok Hospital, a chain of hospitals in Thailand. The CEO of BH is a pediatrician and the chief of staff is a retired army physician whose last assignment was surgeon general of the army. They were both very friendly and made the travel in Thailand as smooth as possible. I recommend having a general on your side whenever traveling abroad.

Our hosts took us to a presentation of a national epic story, with fabulous costumes.

Dr. Shogren-Knaak at the opening ceremonies. The king of Thailand was one of our sponsors so we all got shirts in his birthday colors for 2013. Dr. S-K is giving Lance a view of the proceedings. She appears to be in good spirits despite wearing damp underwear for the last three days.

Susan Lee, a medical student from Rochester, place a laryngeal mask in this young woman.

Traci and Chorladda, one of the CRNAs who helped us in the operating room. The nurse anesthetists were good clinicians and good hosts. Traci is old-school, uses a precordial stethoscope.

This unfortunate lady suffered a bad burn with scarring. The contractures made for a difficult airway: limited neck extension and reduced ability to open her mouth.

We made lots of plans about how to manage this lady's airway. Glycopyrrolate to dry her mouth, topical lidocaine in her mouth and nose, and an inhalational induction. Her mouth didn't open enough to place an endotracheal tube or laryngeal mask, so plan C was an asleep fiberoptic intubation. You can see the endotracheal tube loaded on the bronchoscope. Adrianna Herrera, anesthesiologist from Yale, is doing a jaw thrust to make a space for the bronchoscope to pass through the hypopharynx.

On Saturday, after the work was done, our hosts took us on a cruise on a lake near Udon Thani. The lake is famous for the lotus plants that grow there.

Saturday night our hosts threw a party. I have never seen so many lovely costumes (not to mention the ladies wearing them). These folks were hospital personnel dressed for the dances that were part of the proceedings.

After dinner there was karaoke. I couldn't leave without performing my cover of "Close to You".  Karen would have been proud.