Monday - Operating Theater and Public clinic

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Ugh. Every night I’ve been waking up at 3am with severe trouble falling back asleep. I had plans to go to the gym but I just have to sleep more. Ali picks me up at 8:30am after I down incredible amounts of instant coffee and we pick Scot Hoffinger up from the medical school where he is giving a lecture. There are large hanging signs in the building featuring the graduating medical students in different movie or TV scenes (Soprano’s, Suicide Squad, etc). It’s awesome! Great to see the students having fun. Iraqi medical training is a combined program of medical and undergraduate education for 6 years – much like Australia and European programs. I am excited to give my talk the next day. As I have been informed, there is only one female Orthopaedic surgeon in all of Iraq, so I think it will be great for the students to see.



We have operating theatre from 9:30am-2pm. I have two cases scheduled. The first is quite routine, a subtalar fusion. I have two residents working with me and about 5 surgeons observing. I am more used to the flow this time. All is going excellently until I ask for an x-ray and I’m informed there is only one x-ray machine, and Scott is using it in a difficult case and can’t share the machine. I simply cannot proceed without an x-ray. So I wait. And wait. For 45 minutes. At this point, I can’t wait any longer. The longer I wait, the higher the chance of infection. I put in a screw, and then an additional screw, all blindly without x-ray. Overall I am happy with the construct from what I can tell. Finally, the x-ray machine rolls in as I am closing the skin, and I see that one of my screws is not optimally placed, but does the trick. So I leave it.



And here is where things get sticky and complicated. I want to teach the RIGHT way to do things, even if it means going against the grain and sticking to my guns. However, I have to put the patient first. And in surgery, there are the “best” ways to do things, there are acceptable ways of doing things, and then unacceptable ways. Nothing about that screw was unacceptable. It just wasn’t ideal. And I want to show them the best – isn’t that sort of why I am here? But what do I do, scream and cry until I get the x-ray machine? Compromise the care of the other patient who needs x-ray for his surgery? Keep my patient asleep for 4 hours and increase his risk of infection? The ethical dilemmas are far from black and white.



The second case is an amputation on a diabetic woman who was very mismanaged in India. At first, they try to cancel the case because the first case ran long and we are supposed to leave by 2pm (the surgical staff is on salary, and have no motivation to stay late.) I beg Ali to let me proceed. I say that as long as the case is set up, I don’t need a scrub tech. Finally I get him to agree, but I can tell I’ve pissed off the manager of the surgery center. I don’t care. The woman needs this surgery. Many of the surgeons don’t utilize this type of amputation, and I want to teach them the technique because it is more functional that the typical below-the-knee amputation. The woman has an obvious infection one we open the ankle joint, so I'm even happier I stuck to my guns - she needed this. Case goes well with good teaching and the resident is eager to learn.



After, Waleed informs me that in the time we finished 2 cases he would have finished 5. Thanks Waleed. =) I told him I understood, and surgery is a balance between technique and speed, but I cannot see how 5 cases could be done safely in that environment. And he agrees. But he states the waiting list is so long, if they didn’t do that many cases, the list would be years long. Again, an ethical dilemma that I’m not sure how to solve. I’m sure there is a balance somewhere. I bring up how Scott is in the other room FIXING a bad surgical result in a 16 year old. A case that was probably done quickly without focus on technical excellence. If it was done right the first time, we wouldn't have to use OR time to fix it. This cannot be the right answer. The hand surgeon comes in and finishes Scott's case (he does a brilliant job with tendon transfers) and we leave.



We have lunch in this really cool roadside restaurant with individual cubbies with sliding glass doors (probably plastic doors actually). The immensity of food is again ridiculous, including two full birds, a male and a female. The meat is almost black. It is an Iraqi delicacy, but I don’t care for it much. It is dry and gamey. Waleed offers me what looks like a soft candy after the meal. I try it and it’s awful. Turns out it’s tree sap. It tastes like bitter detergent. It’s in my teeth for hours. I ask if there is any gum I could buy, and Waleed pulls over and buys me every pack of gum there is in the store. The Iraqi generosity.



I then realize that clinic starts – when we arrive. There's no rush about things. It’s about 5:30 now and we work until 9:30. More interesting cases, a lot of complications in diabetics. A local doctor joins me, and brings me fruit and dates as gifts. He does much of the diabetic foot care in Iraq, so it is helpful that I can refer the patients to him for follow up. He’s a bit aggressive and interrupts me constantly, but I appreciate his expertise with the Iraqi system.



I turn down dinner at Ali’s house, I’m just done and still full from that ridiculous lunch. I go home and pass out and, like every other night, wake up at 3 am and can’t fall back asleep. I wish my internal clock would reset already.

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