This wasn’t my best day. Or the most ecstatic, exciting, thrilling… etc.. In some ways it was even better: today I had a very contented day.

The morning started off typically with a bit less sleep than needed (but Becky continues to get multiple baby interruptions every night so no complaining!), and I went to morning rounds. At morning rounds the Nepali docs on call the night before present any admitted cases, and occasionally get a few friendly questions from their seniors. I remember in my first few weeks not understanding more than 60% of what was said due to Nepali-English accents, different acronyms for common medical things, and new diseases/conditions I didn’t recognize (e.g. scrub typhus, ‘alleged-fall-from-tree’, unknown-bite etc…).

But this morning I understood everything, and no major surgical disasters had been admitted the night before.

Before the rounds, the tradition here at the hospital is to read a snippet of scripture, a short extemporaneous prayer, followed by a short prayer for the staff of the hospital rotating through all the departments (nursing, medical, rehab, admin, support services, security etc…) It is a nice tradition, although at times I wonder how the predominantly Hindu Nepali student doctors feel about the readings and prayers, since they sit respectfully and silently until it is done, with no interaction. This morning after the scripture it was my turn, so I prayed for us doctors to treat our patients with empathy, to avoid the temptations of arrogance and pride as we dealt with overwhelming numbers of predominantly poor and less educated patients. My prayers are often auto-biographical in nature — how else can I pray but to simultaneously give thanks and confess? Thats enough for another blog post some day…

Rounding on actual patients takes another 2 hours, and was more enjoyable today despite being longer than usual. I was the only senior surgeon (Dr. Arun is at a meeting in Pokhara 5 hours away, and Dr. Samir is on holiday), so our two teams joined together and rounded on everyone together. I tried to keep things efficient, but peppered some of the juniors with some questions clarifying their thought process around patient care. Generally the medical knowledge of the junior docs is good, but their approach is sometimes a bit… fuzzy. Perhaps the difference between book-knowledge vs. street-smarts. I attempt to get them to make a plan, take a stand, whether or not it is the ‘best’ plan in the end. Today the educational cocktail seemed to work. Smiles-all-around.

One of the other joys is promoting the autonomy of one of the recently-trained general surgeons back from China. (Residency training spots in Nepal are in short supply, and hard to get into…) She has had a fair amount of experience in some areas, but needs probably another 2 or 3 years of mentorship before becoming a senior surgeon here in Nepal. She is conscientious, asks good questions, is appropriately confident without being reckless, and wants to learn. In addition she doesn’t mind challenging us senior surgeons when necessary: which is not always common in the very hierarchical Nepali medical system. A good thing.

The OR starts at some vaguely-mid-morning time after Nepali tea / snack has occurred. Must Keep Our Priorities Straight! At first – I was disappointed that two of the “big” cases today didn’t show up. One was a woman with a biopsy-confirmed breast cancer who was to come for a mastectomy and axillary dissection. This operation isn’t performed very much here in the hospital (although was common back in Canada), because most women present very late in the course of their disease with breast cancer metastases in Nepal and thus may choose to go back to their home to prepare for their death, or they may choose to travel to one of the few cities where palliative chemotherapy is offered. I was looking forward to doing a surgery in which I actually feel that I have significant competence & experience, and lots to teach to the residents. Strike one. (And in retrospect I was the one praying about pride/arrogance only a few hours earlier… Sheesh.)

Strike two was the other big case: a liver ‘hydatid cyst’ which is interesting, and rarely if ever seen in Canada. Basically a larval-tapeworm finds its way into the liver, and makes a big cyst, and reproduces. It is a fascinating case for a Canadian, as I’ve only seen about 5 of these in my life, all in Nepal or Uganda/Kenya. But this patient also didn’t show up.

The remaining cases at first glance looked somewhat more routine: #1. C-section, #2. removal of Ovarian cyst #3. hydrocele repair #4. appendectomy. (Although in retrospect, the first 3 cases would be done by other specialists in Canada.) But what seemed somewhat pedestrian turned out to be a great opportunity for teaching. The two other residents in the OR that day were both fairly junior, but eager, and so — we really slowed down the day, and I got them to do about 95% of the operating. With a combination of good-natured-teasing, demonstration, alternating from operating-to-assisting-back-and-forth, questions/trivia, and infrequent scolding… we muddled our way through the day. They had a good time, (junior docs typically love the tangible success of having “performed surgery” for the first time) and in the end I didn’t mind that the two “big” cases hadn’t come… One of the challenges being here is giving the Nepali docs autonomy to operate: back home I wouldn’t dream of letting a first year resident do an entire C section on their own, but here the community standards, and the needs of Nepal are different. And so I try to get them up to speed as quick and as safely as possible. And today – by hook or by crook, I think it worked out.

After the OR – I got to have a more informal chat with one of the anesthetic nurses using my broken Nepali where we covered a variety of burning questions she had about the Canadian health system. She also wanted to know how we “missionaries” were getting paid (answer: complicated and varying), and if we were sending any money back to Canada. (yes we are, but not in the way that you think?! Most Nepali’s working abroad send remittances home – which probably represents a whopping 25% of Nepali GDP)

Then after coming home (the commute is about 37 seconds door-to-door) I got to play with the kids a bit (Freda and I played Old Maid, and eventually she confessed that she recognized the ‘bad card’ because it had a rip in it), dance to some music with baby Dot who is still enjoying cruising the low-lying furniture at home, and then read a few blogs before getting Silas off to bed. I’m on call tonight, but Becky agreed to watch the phone while I went out for a walk. The heat in Tansen has started to be a bit much during the day, but for some reason it was cool and gusty-windy with a full moon, just the kind of weather to inspire some bloggable-thoughts, and so I took a stroll up to the school about 50 metres up the hill, and looked out over the valley. The little lights from the small scattered rural houses seem like a mirror reflection of the stars as they are fairly evenly spread across the hills – both horizontally and vertically. The night is clear.

I don’t know what tomorrow will bring. But I’m grateful for days such as this: where momentarily I feel like we’re in the right place. A stupendous blurring of the mundane and the sacred. What a gift.