Friday. Day 1 of the Conference. Case 1 in the operating theater.

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March 31st 2017
Published: April 6th 2017
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I’m writing this while sort of listening during the conference and scratching the 7 bug bites on my legs (who knew, mosquitoes in Iraq). So pretty similar to what I would be doing during a conference in the States. The conference resembles most any orthopaedic conference. I am the only woman. There are some women vendors working the booths outside, all in hijabs. Rumor has it there is a female plastic surgeon from Germany who will be speaking but I haven’t seen her yet. However, everyone is very welcoming and I feel no weirdness or strangeness as a woman. The other surgeons are warm and we make introductions and discuss our practices. We have expert speakers and case presentations. It is all in English and there is a vendor hall with freebies and treats for the surgeons to lure them into discussion. There is a fabulous elderly surgeon who gets up to speak after almost every talk and holds the microphone very close to his face while he mumbles his expertise. There are some obvious differences. The technology available here is far less advanced than the U.S., from surgical implants to diagnostics tests and imaging. I give a talk on infections and am able to answer some relevant questions; however, some questions are hard to answer because in the U.S. I would treat infectious via techniques not available in Iraq.

After lunch, Ali and I head to the private hospital so that I can perform the reconstructive surgery on his wife. We pick his wife up from her home and you can tell she is nervous. The car ride is pretty quiet. We drive about 45 minutes to the private hospital. There is no credential check, I don’t have to sign in, no one asks who I am. Outside of the operating theatre, I am told to take off my shoes and am given a public pair of clogs. I am given paper scrubs to don over my clothing. The OR is very simple. Anesthesia machine, metal patient table, portable metal back tables to hold the instruments, an xray machine of good quality. They have one tourniquet which is 80 cm in length (HUGE) and wraps around her leg 4 times. They have no padding on the bed. I ensure we have the appropriate sterile equipment on the back table. She is put to sleep in about 10 seconds (takes a solid 20 minutes at Stanford). I am ready to start.

To my surprise, Ali comes to the sink to scrub his hands. He is planning on doing the surgery with me. For obvious reasons, performing a surgery on a surgeon’s wife with him as your assistant is wrought with potential problems. However, there isn’t another assistant and it’s obvious this was his plan, so I elect not to object. We scrub at the sink with communal scrub brushes as the nurse constantly pours soap on our hands and then our arms are drenched in alcohol. We prep the patient’s leg sterilely. We then drape out the table and the leg with multiple sticky half sheets. I double check the patient has received antibiotics (there is no formal time out process). There is no sterile x-ray machine cover. I elevate the tourniquet and begin. I’m anticipating a surgical time of 1.5 to 2 hours.

The surgery takes 3.5-4 hours. There are two parts of this procedure, one which is usually quick and straightforward and the other which takes a bit more time and care. The easy part turns out to be the far most challenging. First, the equipment is old and faulty. In this case, I need to make multiple bone cuts to realign the foot. The realignment is held temporarily with wires and then ultimately secured with screws. Wire placement is typically relatively easy. With this equipment, however, every time I need a k-wire, it needs to be loaded into the drill and then locked with a chuck key. The chuck key is worn and takes a few tries every time to engage the drill. And then the wire needs to be unlocked and locked again halfway through the drilling process to complete each pass. A technique that takes 20 seconds in the U.S. takes about 1.5 minutes here. Seems like not a huge deal, but this time adds up quickly when multiple wires must be passed. Not to mention, during the drilling, one of the assistants is holding the proper alignment. This is tough to do for 20 seconds much less 90. So often the alignment would shift after wire placement and we would have to start all over again. Second, in the U.S. often we will place the wires strategically with xray. Since the xray machine is not sterilely covered, I need to place all the wires blind and then check them after. This leads to the need for more wires to ensure perfect placement. Third, no one in the OR has ever seen this surgery before. So it is very difficult to explain each step and direct how they can assist properly. Fourth, the language barrier is hard. The scrub nurse rarely understands the instruments I am asking for. Every time we need suction, the nurse must come around and turn on the machine. The xray techs don’t stay in the room. The knife blades are cheap and dull. Fifth, the large tourniquet is only partially working. So the field is bloody which makes each step harder to navigate. And lastly, and inevitably since I am operating with the patient’s husband, anytime the operation isn’t going perfectly smoothly, he asks “Why didn’t that work? Why do we have to do this partagain?” One time he was being so aggressive I thought he may break his own wife’s bone. At this point, I had to be firm and make sure he understood that he needed to follow my lead.

All in all, the surgical outcome was desirable and the patient will do great. But wow – eye opening! And humbling, just like my job is every day. Just when you think you have it all figured out… you don’t. It made me very thankful for my team back at Stanford. They make my job easy.

Things I will bring if I return to Iraq (for myself so I don’t forget):

Sterile xray machine covers

A quick collet for the kwire driver

Suture passers

Lamina spreaders

Sterile esmarchs

Calcaneal osteotomy plates

Things I would have done differently for the surgery:

Patient positioning: Feet at the end of the bed, insisted on more padding

Assume the case will take longer than expected

NOT scrubbed with the patient’s spouse

After the case, the family is very grateful. They apologize for the length of the case. I apologize for the length of the case. The anesthesiologist drives me back to the hospital where I make it in time for the “ceremony”. It was a celebration for the medical school and a thank you for the visiting surgeon. We received two plaques on stage presented by the governor of Basrah. I’m informed in advance he cannot shake my hand for religious reasons. First time I ran into that. We do a mini bow and I then make a quick exit. It’s now 10pm, I eat my dinner of chicken kabobs, and have a very restless night’s sleep.


6th April 2017

Not a typical travel adventure...
you are amazing!

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