Sunday was a Crazy Day

The team: Amahl, Teresa, Samer and I met breakfast at the hotel before heading off to the hospital. My previous experience with screening on the West Bank involved pediatric urology and a surgeon who spoke no Arabic. Today was much different, with patients coming in suffering from medical illnesses that would not benefit from surgery. We did two cases in the operating room. One was especially memorable: a fourteen year-old girl for a revision of her ventriculo-peritoneal shunt. I did not have her endotracheal tube sufficiently secured and it came out while the surgeons were tunneling the distal portion of the shunt. I tried deflating the cuff and blindly pushing it back into her larynx without success. At this point standard procedure would have been to tell the surgeon to cover the wound, pull down the drapes and re-intubate her. Since she was well oxygenated I removed the tube and put a mask over her face, giving her gentle positive pressure ventilation. Happily I did not use a muscle relaxant for this case so she started breathing spontaneously within a few minutes. I had a stable, satisfactory situation so I kept this up for the forty minutes it took to complete the surgery. Given the risk of shunt infection with a break in sterile technique I think I managed the case appropriately. I want to stress to anyone in an anesthesia training program that this is not the management I would describe to a board examiner. Keep in mind the sentiments found on this box of exam gloves.

Photos from Nablus

We got to spend some time away from the hospital and the operating room. We finished early one day and got to visit Jacob's Well, where an Orthodox church is built over the well where Jesus asked a Samaritan woman for a drink. I had some of the water. It was pretty good, and an hour later I was thirsty again, just like He said.

Here you see a bucket leaping out of the well.

I think this picture tells of the life of St. Bartholomew,
who converted a king of Armenia (l.) before being flayed (r.).

Amahl Jubran, Teresa Bubb and Samer Elbabaa. I loved
working with you guys and hope to do so again. 

Dr. Achman (seated on left), the neurosurgeon from Nablus, was a great host in the hospital
and invited us to a cookout at his home Friday afternoon. 

Eating luz (green almonds) from Dr. Achman's orchard.

A very busy Tuesday (this is the one with pictures).

We got a bit of a late start and began our first case about 9:30. This was a two year-old girl with a misshapen head. As a result of a misunderstanding on the part of the intern on call, her head was completely and needlessly shaved. The surgeons peeled her scalp down and removed most of her frontal bone. They reshaped it and changed its contour with partial fractures, then repositioned it over the outer lining of the brain. They put mesh around the lower corners to accomodate growth and fixed it into place with tiny titanium plates. Very cool.

In this photo the frontal scalp has been peeled down, the forehead part of the skull removed, reconfigured to allow brain growth with a more normal head shape, and the skull stabilized with titanium plates, screws and mesh.

Next was a twelve year old girl with a bony tumor on the surface of her skull. She, too, had her head shaved. This case was a bit complicated for me because the only endotracheal tube that was appropriate for her size was a bit shorter than ideal and kept getting pushed from her trachea into her right bronchus. The case was done in collaboration between Samer, our neurosurgeon, a Palestinian oral surgeon and a Palestinian general surgeon. Every time I went in to adjust the tube I had to elbow one of those guys out of the way.

In this photo Samer, our surgeon, uses a mallet and osteotome (a chisel), to take the bony tumor off the girl's skull.

The third case was a six month old with hydrocephalus and a huge head. His intubation was rather difficult but a rolled-up towel beneath his shoulders allowed me to extend his head enough to visualize his vocal cords and intubate him. It's kind of a shame that the hospital doesn't have a resident working with me since these are good teaching cases. On the other hand, I'd have to let him do the airway stuff and that would drive me nuts.
The icing on the cake was a newborn, twenty hours old, for closure of a meningomyelocele. This is far and a way the youngest child I've ever anesthetized. The hospital opened a second room for us so I used an unfamiliar anesthesia machine and monitor and had the patient prone to boot. I was very happy they had an endotracheal tube small enough for him.

We celebrated our big day by going out for coffee, dessert and a little smoke before returning to the hospital.

From Damoh to Nablus

Rai and I testing out the camera before I buy.

I left the children's home early on Friday February 18. The drive to Jabalapur was beautiful. We saw black-faced monkeys, a pair of jackals, a small herd of deer being watched by a buck with a great rack of antlers, and a WILD male peacock. It never occurred to me that I might see one in the wild in India. Our flight from Jabalapur to Delhi was a couple of hours late but made it to town in time to buy a little outfit for Katie Rose and a camera for myself. We ate in a great restaurant. Mr. Rai, our travel agent and my minder, is a big fan of Indian buffet and so am I! After lunch I bought a camera, so now there will be some photos.

There was a wedding outside my room, so I didn't get to sleep as early as I might have.

I was up early the next morning for a 0300 ride to the airport. The flight to Amman took off on time. I sat next to a computer guy who was leaving Delhi to go to Germany to be with his wife. Kind of romantic, leaving a position at the university for love.
The Amman airport is rather poorly organized. The security guy wanted to confiscate my laser pointer. I kept talking until he told me to shove off. When we arrived in Tel Aviv, the belt that conveys bags to the carousel jammed, leaving about fifteen bags (including mine) stuck on top. Now, of all the adjectives that might be applied to me, NIMBLE is not among the top two hundred. I was amused with myself by stepping up onto the carousel, moving with the belt, and climbing to the top where I could throw down bags. I hope the Israelis don't review the surveillance videos before I try to leave next week.