Volunteer Expeditions

Playing Tourist

2008-07-12T20:46:00.000-07:00

Apparently it rained every day this week. Had I known that, I may not have been so surprised when it started pouring during my hike through the cloud forest. OK, the name maybe could have given me a clue to expect some dampness. But the day actually turned out to be quite a good one.

Everyone else left early this morning to head back to the States, so I took the opportunity to see a little of the city I've been working in for the last several days. I hired a driver - Julio - who took me to see a few sites.

We started at the artisan and agriculture fair which takes place every Friday and Saturday next to the National soccer stadium. It was rather impressive and organized. And the market was easily identified by the omnipresent blue plastic rain/sun shades.

The fruits and vegetables were separate from the meats and seafood which were separate from the clothes and housewares. You could buy everything you need (and don't) here. There were bouquets of flowers and bouquets of carrots.

I even got to see a machete being used for its intended purpose.

Julio accompanied me into the market as well as on my hike. I think he was afraid I might get lost. Smart man. Halfway up the trail he tried to convince me we shouldn't go any farther. It's very dangerous up higher - hay culebras. My Spanish is not so good these days, but was he trying to tell me there are cobras up higher? Did I listen to the man who has lived about 40 years in this city? Nope. Up we went.

The forest was beautiful, and wet. But I liked the sign up at the top: Teach your children to live in harmony with the forest.

The sun did come out for us when we went to see El Cristo de Picacho, which is visible from the Hospital Escuela. It's like a mini Corcovado. You can see the whole city.

I was able to straighten out this picture on my computer, but it was so funny watching Julio try to frame the shot, and then take this one.

And I couldn't go home without doing a little bit of shopping. We drove to La Valle de Angeles, where I finally had some Honduran food, or at least so I thought. Julio and I had pupusas served with pickled vegetables, which were delicious. And then he told me they are actually Salvadoran.

He was my favorite shopkeeper.

Daylight!

2008-07-11T21:26:00.000-07:00

Today was truly an exciting day. I got to go outside. Before I get too excited about it, this is how the day began.

We rounded quickly on our patients, the ones slated for surgery today and the ones we operated on yesterday and the day before. Here is a room of post-op patients, hands elevated (as instructed) in greeting. If only all my patients at home were so compliant.

I did a couple of cases with Carlos in the morning, including this 64 year old woman who sustained this injury in an automobile accident. We treated her wrist (distal radius non-union) today, and at some point she will have something done for her elbow which barely moves and is quite painful. I wish the upcoming surgeons luck operating through the skin graft and underlying scar tissue.

We excised the distal end of the ulna, using that bone to graft the distal radius defect, and then spanned the joint with a plate. I would show you the post-op xrays, except that they don't take any. For that matter, we didn't take any intra-operatively either. That took a little getting used to, especially placing pins percutaneously, but it really makes you rely on your clinical skills and not so much on technology.

I joined Michelle, Tessa, and Oscar for a delicious lunch at McDonald's (this was the beginning of the exposure to sunlight). Since I had forgotten to get a Frosty at Wendy's the other night, I made up for it by having a McFlurry today.

I went back to the hospital to do one more case with Claudia and Carlos, but they shooed me out of the OR and told me to go see something other than the inside of the operating room. They said McDonald's doesn't count. By this time the night shift (after 1pm) had come on. They are so fun and lively, and they seem to really enjoy their work. I wish to god I could remember their names!

I'm not sure if they're doing this purely for entertainment or to distract the patient while his regional block set in, but here Carlos and the anesthesiologist and the patient are singing a Honduran song together. I wish I had remembered that I have movie capability on my camera. Next time.

Claudia and Carlos then set to work on yet another tendon transfer for an old machete injury. Could you identify the other injuries from that machete in the last picture?

When I left, Oscar and Guillermo took us to the MIN - Museo Identidad Nacional. Unfortunately, because of the traffic getting there, it was just closing, and then it started to rain. But it was nice seeing the downtown, all of which was underwater after Hurricane Mitch in 1997.

We then went to the new Honduras Medical Center to see the little girl who had surgery last night from her meat grinder injury. Turns out, she comes from a Menonite family from Missouri. She was moved to this hospital this morning - what a contrast between Hospital Escuela and this. I did not expect to see this kind of economic divide in health care here. In the Hospital Escuela, the price of admission is a pint of blood, if not from the patient, then from a member of the patient's family.

The little girl's fingers do not look great, but they also do not look doomed. I still have hope. Her family was so grateful they insisted on having pictures taken. The poor girl - I'm sure she would rather not have to see us ever again. They also gave us each a homemade frozen yogurt treat which was delicious!

On our way out we had the opportunity to meet Guillermo's wife Sandra and 2-year old son Gabriel. They live in San Pedro Sula (a 4-5 hour drive away) and are in town for the weekend. I don't know, Jasper, someone might be giving you a run for your money in the cheek department.

The day would not be complete without visiting another top notch eating establishment. Tonight it was TGI Friday's. I can't wait to eat some vegetables when I get home!

Fine Dining

2008-07-10T22:47:00.000-07:00

Today at about 3:30 pm I had a delicious chicken breast for lunch. It was moist and tender, and came with a biscuit, fries and a large soda - all delivered to the OR lounge. I'm beginning to think Honduran food is American fast food. In fact, here is the view out my window, and then a view from the other side of the building:

(The bluish building to the left of the Marriott is the hospital.)

Actually, we did all go out for a really nice meal on Monday night with the house staff to a restaurant called El Patio. On the way there we passed McDonald's, Wendy's, Pizza Hut, Little Caesar's, Appleby's, Tony Roma's, Popeye's, Burger King, and I'm sure I'm leaving out at least a half dozen more. But El Patio served real Honduran food, and was quite tasty.

From left to right: Tessa (Michelle's daughter), Michelle, Jean, Guillermo (standing), Oscar, me, Carlos, Emily, and Claudia. Michelle is a pediatric orthopaedic hand surgeon who works at the Shriners Hospital for Children in Sacramento, Jean and Emily are hand therapists. Carlos and Oscar are first year plastics residents and Guillermo is a third year. No, there are no second year residents. Claudia is a plastics fellow, and her 10-year old son Andre is taking the picture.

(Left to right: Carlos, Guillermo, Oscar)

I had the privilege of working with Claudia for the first two days in the OR. Her skills are outstanding. She is doing a year of rotations in the States focusing on hand and microsurgery. She just returned from Kansas and next month will be returning to Little Rock. I am very glad she came back home for this month. When she completes her fellowship, she is hoping to return with an appointment at the Hospital Escuela. She clearly loves to teach, and it is clear that everyone in the hospital loves her. Andre says he would like to be a doctor too - and he says so in perfect English.

Carlos has also been working with me. I mentioned earlier that I thought the usual attending/fellow/resident hierarchy was funny in this situation because after finishing his three years of general surgery residency, Carlos was chief of surgery at a 100-bed hospital in the western part of the country for 9 years before coming back to do his plastics residency. He is hoping to continue with a hand fellowship when he is finished here.

Oscar, on the other hand, went straight through from general surgery to plastics. I haven't had the chance to work with him as he has been in the OR with Michelle in pediatrics this week. He is planning on a specialty in burns when his three years are completed. He has two beautiful daughters aged 1 and 4.

Guillermo is the chief. And he is quite a character. He is often goofing around, always has stories to tell, knows all the words to all the really bad easy listening American songs that come on the radio, and he tapes an earpiece to his ear so he can answer his phone during surgery. I am pretty sure he doesn't do it for ER calls. After medical school he practiced general medicine for three years, returned for three years of general surgery training, practiced general surgery for three years in a small community hospital, and is now back for three years of plastics training. Sounds like me - short attention span. Recognition is the first step...

Louie was unable to make it dinner with us that night. But apparently he has been hosting various TV stations doing pieces on our being here. He is very hard to keep up with. He works, and walks, as fast as he talks, and he talks a mile a minute because he has so many thoughts going through his head at once. This morning, I was left to fuse a wrist in a n 18-year old boy while he and Guillermo got to play with this bilateral near-amputations resulting from, guess what, a machete. Not fair.

Oh - sorry: gory picture warning. And no, not pictures of my now elephantine ankles.

Louie did a fellowship in hand and microsurgery similar to Claudia, spending three months at a time at various institutions in the US. His English, like everyone else's, is almost perfect. Thank goodness, because all that's coming out of me is Italian. He was quick to note that he is a year younger than I am. Reminds me of someone else who likes to point out that I am a year (and a day) older than he. He has an incredible amount of energy. We have special privileges to operate all day this week (usually the OR closes down to emergencies only at 1pm), so he wants to make sure the schedule is full, and if someone has to cancel for some reason, he finds someone else to take that spot. So, as in an institution I work in at home, occasionally there are surprises. I had to draw the line this evening when a 20-year old boy with cerebral palsy came down to the OR for a wrist fusion. It has been years since I've treated one of these kids, and without the proper equipment, I thought it best to put it off until someone more appropriate could do it.

So I went to the pediatrics side where Michelle's surprise of the day turned out to be a 5-year old girl who accidentally put her hand in a meat grinder as she was helping her father with his work. The grinder went around, cutting each finger twice down to the bone, and would have kept going up her hand and arm had the motor not thankfully stalled. Michelle and Oscar did what they could to save her fingers, and I have hope that they will survive.

After another 13 hour day, Guillermo, Oscar, Michelle, Tessa and I went out for a bite to eat - at Pizza Hut.

Fat Ankles 2

2008-07-09T21:21:00.001-07:00

Gnarly picture warning.

Seriously - what is with the fat ankles?? Would someone with a better understanding of fluid balance than me please explain why this keeps happening? Please? Or am I doomed to have swollen ankles every time I go on one of these trips? If I had taken off my socks you would have seen nice little rings of indentation.

Boy - they are really working us here. Just spent 13 hours in the OR (on stools with no cushioning!). Every case was a head-scratcher. There was a lot of discussion and decision making on the spot, which was fun, but exhausting. I can't even remember how many we did today, but I sure was ready to be done. What exactly did we do? You don't really want to hear about the girl whose machete injuries occurred when her uncle tried to kill her after he raped her, do you? Didn't think so.

They had a pasta bar at the hotel tonight, and I was hoping to have myself a bowl of caccio e pepe, but no such luck. Carlos and I went to the Wendy's drive-through on the way back to the hotel. Don't believe me?

And for those of you who still don't believe that I am actually working, check out today's paper.

That's me in the foreground, trying to help Claudia with a very difficult case.

The guy in the small picture below is Dr. Luis Gonzalez, the director of the residency program for the last three years. He is quite a charismatic person, full of energy and a huge proponent of education at all levels. Claudia and I walked in on him giving a lecture on microsurgery to a group of interns. Unfortunately, the air conditioning was off in the little library because it was set on a timer - Louie (as he likes to be called) thought it was broken!

The goal, as I understand it, is to fully staff the Hospital Escuela and the pediatrics hospital, and then farm out well-trained plastic surgeons to other parts of the country that are in need. Here, as is the case in one way or another all around the world, he has had to battle some opposing forces, both from within and from without the institution. Fortunately, I think, the program is moving forward, and he has a group of very talented and enthusiastic residents on hand right now.

As we reviewed the day's OR schedule, Louie felt we were not adequately using our time, so while we worked, he went trolling the floors for more cases. He did the same yesterday. The schedule for the rest of the week is slowly growing as a result. I'm going to need a serious vacation after this!

Oh, the gnarly picture? I was referring to my ankles.

Can't See My Blog!

2008-07-08T21:43:00.000-07:00

I don't know what it is, but once again I cannot view my own blog. So, I apologize for any previous and any upcoming errors in spelling, layout, picture formatting, etc. It's not my fault.

OR Day #1

2008-07-08T21:05:00.001-07:00

Here is the week's OR schedule. Notice how many are injuries from machetes. If you can see, the gray cases are to be done in the pediatrics OR, and the white ones in the adult OR. I guess age really doesn't play a part in making these decisions. Everyone on the list was seen in the clinic yesterday, and admitted to the hospital, much to my surprise. We stopped on the surgical floor to see our first patients, and then off to work we went.

As we were gowning for the first case Claudia asked me if I use disposable gowns. I felt myself starting to cringe, thinking about how much waste we generate each day in the operating room. They reuse bovie pads, tourniquets, esmarch (by exsanguinating the limb before prepping). We sometimes use a suture down to its last centimeter as a technical challenge; they do it because if they don't, there might not be another suture to finish closing the incision. We toss completely unused, untouched items like sponges; here they are folding gauze to be re-sterilized. I realize we live in a different world, but clearly ours is not always the more sensible.

To answer Claudia's question, I was able to tell her, truthfully, that I use disposable in some places, and cloth in others. Although this is true, it didn't really make me feel any better.

Operating today was fun, and more than a little challenging. I had Claudia and Carlos with me - a fellow and a resident. I will tell you more about them later, and you will see why I find this hierarchy - me: attending, Claudia: fellow, and Carlos: resident - really funny. They are both talented surgeons, inquisitive, and rather funny. Here's our OR, and I was glad that we were able to use the tourniquet machine I brought from home.

Our first case was that of a 16 year old boy who had a run-in with a coffee processing machine (I think) three months ago. His right hand was crushed, leaving him with a painful, completely non-functional hand, with so much tissue loss that he required an urgent groin flap at the time of injury.

Today we performed capsulotomies of all fingers at the MCP joints, trying to position his hand a little better, so it may in the future be used as a helper hand. We also explored the median nerve, found a ball of scar where it had been cut, and tried to bury it so he might have less pain. This is when staying here only a week becomes frustrating - I will not get to see how he does, but hopefully will get some follow-up from Claudia and Carlos.

The second case involved a 21 year old who took a machete to his forearm. Look how far around it went. Needless to say, everything was cut, including the ulna. For those of you in orthopaedics, notice there is no posterior incision. The ulna was plated from an anterior approach - and that was how we went in to get the plate out. I did not enjoy this case very much, because it also involved trying not to disrupt the grafted nerves and artery. Thankfully, when the tourniquet went down, the hand and fingers all turned pink.

Meanwhile, over in peds, Michelle was hard at work with Guillermo and Oscar, and this medical student who just didn't know what to do with his left hand. Either that, or Guillermo really pissed him off!

Despite some obvious differences, some things here are not that much different from home. I wasn't quite sure why we had so much time between the second and third cases. I later discovered it was shift change. Ah - some things, I see, are universal.

And this is the orthopaedic storage closet. Looks an awful lot like my own.

Clinic

2008-07-07T20:30:00.000-07:00

When I got back to the hotel this evening, I thanked my lucky stars for all my fingers and all my toes (and not too many of them). Here is a smattering of what we saw in clinic today. From what I understand, for the four one-week periods when there are visiting surgeons, we see patients all day on Monday, and from those we fill the OR schedule for the rest of the week. Let me just say this - I won't be seeing much of Honduras on this trip!

The morning began with children with a variety of congenital anomalies. Here are Michelle and Claudia examining the cutest one of the bunch. He has a central syndactyly with an embedded polydactyly. I'm not even sure I'm saying that right.

Here is another sitting on his mother's lap. He has a mild form of what his mother has, and his feet are involved as well.

Let's see... 1, 2, 3, 4, 5, 6!

This kid with a radial club hand was not so happy with us.

Some were burn injuries.

Later in the day the machete procession began. The transition came with a 7 year-old boy who sustained an injury to his wrist from a machete wielded by his 9 year-old brother while they were working in a sugar cane field. It was truly remarkable - most of the injuries were months old, many having been treated for bony injuries but the soft tissues, the tendons and nerves, had been neglected. There was a lot of imagination and creativity being employed in trying to come up with some solutions.

Here is a creative solution to a problem. I can't remember the exact circumstances surrounding this woman's injury, but in order to salvage the thumb, the index finger was sacrificed to provide skin to cover the thumb defect. If you look closely, you can see the contour of the index finger on the back of the hand, having served its purpose successfully.

I will write again when we emerge from the OR. Hopefully I will not miss my flight home!

Honduras

2008-07-06T21:45:00.002-07:00

July 2008
Tegucigalpa, Honduras

I have just arrived tonight in Tegucigalpa, by way of El Salvador. This tour is going to be short, just a week at the Hospital Escuela, again focusing on hand surgery, this time through the department of Plastic Surgery. Honduras has a population of about 6.5 million. It is one of the poorest countries in the Western Hemisphere, never mind just Central America.

I am here with Dr. Michelle James from Sacramento, and two hand therapists, one of whom, Jean, I met this evening. I am looking forward to an exciting and challenging week of patient care, surgery, and education. I anticipate learning as much, if not more, than I teach.

Disclaimer: I understand the machete is a common tool here, and thus a common mechanism of injury. I will try to give adequate warnings in the upcoming posts, but I make no promises. Read on at your own risk!

Tashi Delek

2007-04-29T23:55:00.000-07:00

Means “Good luck and Best wishes” in all things, health, wealth, happiness. The best translation I can think of is “Auguri”.

On this trip I crossed the Dochu La Pass at 3340 meters above sea level for the fourth time. And for the fourth time I am denied the allegedly spectacular view of the Himalayas, that is supposed to look something like this.

This is what I see, again.

But on this, my last morning in Bhutan, Buddha has smiled upon me, parted the clouds, and given me this awesome early morning view of Mt. Jhumolari, which straddles the border between Bhutan and Tibet, and rises to over 7400 meters above sea level.

This is Paro Dzong with the mountains behind from my Executive Class seat on Druk Air.

And this, my friends, is the faint outline of Mt. Everest.

Tashi Delek.

I have 12 hours in the Bangkok airport hotel. Gym, pool, swim-up bar, Thai massage. Then I will see you at home…

…maybe!

The People

2007-04-29T23:43:00.000-07:00

You will not find a more warm, friendly, and gentle people than the Bhutanese.

Girls waiting for the bus.

Working the fields.

Farming is a family affair.

School kids.

Dowtown Thumphu.

Downtown Paro.

The village outside Paro where Kado grew up. His house is the large on just right of center, and where his brother now lives. This is where we picked up his cow feed. When he was a kid, he and his brothers would go up into the hills to collect wood. Because they were small, they couldn't carry the wood back, so they rolled it down the hill. And in order to keep up with the wood, they would roll themselves down the hill as well.

This farm woman is carrying a piece of cow dung, used to "transfer" fire. Below she placed the dung in a pile of dry grass, and is making a fire out in the field. Learn something new every day...

More kids.

Playing hide 'n' seek around the war memorial chortens at Dochu La pass. Kids will be kids.

I didn't do too much to prepare for this trip. One thing I did was buy earplugs for the long flights. No need. I fell asleep without them. So I thought I had wasted my money. But when I got to Bhutan I was really happy to have them. I had forgotten about the twice daily routine of the town dogs - barking at each other as loudly as possible at 5am, and midnight.

As mentioned before, religion plays an integral part in the lives of the Bhutanese. This is the Memorial Chorten in Thimphu. The faithful are walking around the structure, with their prayer beads, chanting the mantras of their gurus.

Even thought they're monks, they're still kids. These two got into a little tussle, pushed each other around and dropped their butter lamps down the hill. Oops.

This nun is walking up to Taktsang Gompa, the Tiger's Nest Monastery. She is wearing the traditional dress for nuns, and sensibly carrying her things in a Nike bag.

This is Rinchen, my guide to Taktsang Gompa. (He has PERFECT teeth.)

We ran into this gentleman one day. He is the Prime Minister's father.

The Cult of the Penis

2007-04-29T23:27:00.000-07:00

It may seem a little odd and kind of funny the first time you come across an enormous rendering of the male reproductive organ on the side of a house. You might think the owner is a little twisted. But then you notice more, and more of them. And then you start noticing sculpted wooden penises hanging from the corners of roofs.

The phallus is a revered symbol in Bhutan. Displaying it proudly on one’s home invokes its powers of fertility and protection. The best painting was apparently on the road to Punakha. Sorry, I’ll have to get a picture of it next time.

There is even a temple erected to pay homage to a certain monk who subdued a (female, of course) demon with his member. You can see the temple way in the backgground on the small hill.

This is the mad monk, so called because of the unconventional ways he went about his business.

This is the entrance to the temple grounds, and a prayer wheel, no doubt filled with prayers and wishes for tireless, powerful appendages.

The demon woman is buried here. Why is it demons are always women? No, I don't understand.

Legend has it that if a couple sleeps in this temple, they will soon after be blessed with the birth of a child. No, I did not sleep there, but I did make a wish and receive a blessing from this monk, using two symbolic phalli, one made of wood, the other of bone. Go ahead, start with the jokes.

Food

2007-04-29T22:51:00.000-07:00

Red rice . They sell it in the US at specialty stores, but somehow it just tastes different at home. The grains seem smaller and the texture more firm. Here in Bhutan, the rice is fluffy and delicious. It is also functional. There is a prayer for good fortune, to be able to wash one's hands with red rice. And they actually do - roll a handful of rice into a ball and roll it around in the hands.

Meals are generally eaten family style. Staples include ema datshi (green chiles in cheese sauce), shamu datshi (mushrooms in cheese sauce), kewa datshi (potatoes in cheese sauce), etc. Other foods are similar to Indian and sometimes even Chinese food. (no more Chinese food, please!)

In the village in Paro, I witnessed the cleaning of a (very large) pig right on the banks of the river. Upstream about 100 meters, we were fortunate to find a man fishing. About an hour later he showed up at the farmhouse with fresh trout, which, when cleaned and fried, was scrumptuous.

This is Larry and Mike, joining us in Punakha for a toast of ara. It is difficult for me to describe the taste, it's almost smoky in flavor, and I think, an acquired taste. And just a reminder, take it straight, sip it slowly, and just say no to the egg!

Tea is the more common every day drink. Thankfully, they have black tea and herbal tea, because I never did acquire the necessary taste for butter tea. That's YAK butter tea. They do an interesting thing with their tea. They throw a handful of something like little rice crispies into the cup and drink it all down together. Tea is served with butter cookies or stale biscuits. I don't get the stale biscuits. They're ALWAYS stale. But the cookies are good.

Here's Kado picking up some snacks for us at the local general store.

And here's Kado picking up some snacks for his cows at the local field.

Here's one I didn't try Betelnut. It't their local vice, as smoking is prohibited. I think it's supposed to make you feel a little euphoric - and turn your teeth bright red. Very attractive!

Taktsang Gompa

2007-04-29T11:47:00.000-07:00

The Tiger's Nest Monastery in Paro is perched like a bird's nest 900 meters above the valley floor (which is already about 2200 meters above sea level). One more time - how did they build this?! It was built in the 8th century, and has stood there ever since. In 1998 there was a fire at one of the entrance structures, and was therefore closed the last time I was here. I am glad I had the chance to see it this time.

OK, I admit it! I cheated! I rode a mule up the first half. Turns out I was the only one who did that day. I was more than a little embarrassed when I rode past octogenarians, trudging up the paths with their tree branch-walking sticks. And then after I got off the mule, I was totally winded after the first few steps.

To do list:
1. Call Jenny
2. Get personal trainer

This is the first gate encountered on the path to the monastery. Supposedly, if one passes this gate three times in a lifetime, one will want for nothing. I'm one down...

On the way up, we come across a small temple built into the rock, called Singye Phu. Incense burns at an outdoor altar, giving a holy feeling to the whole area.

This was taken from the midpoint, where we stopped for tea.

And this, is a view of that midpoint at the bottom right, taken from the Tiger's Nest. Paro valley is seen down below.

The views, as you can imagine, were spectacular. The clouds rolling over the mountains gave the mountain a sacred feeling, and reminded me very much of Huangshan in China.

I had met two guys, old friends who have been traveling together for years. They walked. And here, if you look closely, they are taking a well-deserved break.

I know I've been promising Mom all along that I did not drink the tap water. Well, I drank some water. How could I say no? Legend has it the tigress deity threw her crytal prayer beads up this mountain and they turned into a pure water cascade, and all who drink from it will be blessed.

Technically, it's not really tap water...

Punakha Dzong

2007-04-29T11:32:00.000-07:00

Punakha dzong is the second largest in the country, after Tsonga.

The bridge to get to the dzong is just a little precarious. They are in the process of building a new bridge, so that cars will be able to drive right up to the dzong.

They say that beehives at the entrance of a building bring good luck. But this is a little ridiculous!

These life wheels and pictures of the 4 directional deities often decorate the entrance to dzongs, monasteries, temples, and even homes, for blessings.

It is really huge! You wonder about the pyramids, these things are awesome!

Om Mani Padme Om

2007-04-29T09:06:00.000-07:00

Prayer flags line the creeks and pathways throughout the country, praying for all who pass by. Each time the wind blows, the prayers are spoken. White , yellow, red, green, and blue, in order. Blessings are bestowed upon every person and animal downwind or downstream.

Likewise, prayer wheels that straddle creeks turn continuously (clockwise always) by the power of the water, speaking the mantras of guru Rimpoche.

This is guru Rimpoche.

This is my guru.

Monks leave home for the monastery at the age of 5 or 6, and will spend years praying, learning. The ideal length of time for meditation for a Buddhist is 3 years, 3 months, 3 days, 3 hours, 3 minutes, and 3 seconds. Which monastery the litle monks go to is determined, based on how worthy they are.

I particularly like the motorcycle helmet.

Some monasteries are centuries old, but you can't keep the modern world out forever, and sometimes the monks just want their MTV.

Butter lamps are burned on holy days so that after death, there will be light.

On occasion, the faithful are called upon to build a stupa, called a chorten in Dzongkha. For those who can not afford to build a full scale chorten, they can build a small one, of clay, and they are displayed protected in a cave or under a rocky ledge. Sometimes the clay is mixed with the hair or ashes of a loved one who died.

This collection of chortens was built by one of the queens to memorialze those who have gone to war. It is up at Dochu La pass, and is a popular place to come pray on holy days.

Sometimes people are unable to spend the whole day saying the prayers aloud. In that case, they hire others to do it. Some people actually make a living doing prayer readings. Villages often have local temples like we have local parishes. Prayers are accompanied by drums and pipes and chants.

Thursday, 4/26/07 was the anniversary of the death of the founder of Bhutan. It was a government holiday, and everyone went out to pray, picnic in the mountains, walk around the chorten (always clockwise), make cakes and decorate them with colored butter; here, there is a melding of church and state. Buddhisn permeates the lives of the Bhutanese.

Medical Director

2007-04-29T07:37:00.000-07:00

This is Ngawang Tenzing, Medical Director of the Jigme Dorji Wangchuck National Referral Hospital in Thimphu. This is the hospital where I worked in 2001, and nothing has changed much within these walls.

This clinic is the same...

The waiting room is the same - patients are watching TV while they wait for their names to be called...

Outside the walls of JDWNRH (almost as bad as TSCABSMC), however, outside the walls, changes are happening. This is a new 350 bed hospital being built right next to the original structure.

In the meantime, the pharmacy is still functioning...

And so is the ER, but with, it seems, more than the one ambulance they had six years ago.

The problem is, that in the last 4 or 5 years, no one has decided to pursue a career in medicine. They already have a shortage of physicians (there is still only one orthopaedic surgeon in the country; 3 internists in Thimphu and ony 1 in the rest of the country), but in a few years, the deficit will be even more pronounced. There are three who are beginning a residency in Bangladesh, and Ngawang Tenzing anticipates they will return around 2010, but he cannot be completely sure.

There are 20 district hospitals, and several Basic Health Units.

There is also this Indo-Bhutanese Friendship Hospital in Thimphu. There are mid-level practitioners, akin to our physician assistants, along with traditional medicine clnicians who staff these clinics, but there does not seem to be enough.

They are still highly dependent upon outside assistance to fill the gaps, and hopefully we can continue to do so in an even greater capacity. I also hope that we can help them fill in their own gaps, and become more self sufficient.

Accomodations

2007-04-28T10:28:00.000-07:00

Riding in the passenger seat of Kado’s car drew some interesting looks from townspeople. Most assumed I was some kind of royal guest, while others thought I might actually be one of the princesses! There are more people in Bhutan who think I am Bhutanese than there were in China who thought I was Chinese. Go figure.

While in Thunphu I stayed at the Wangchuck Hotel, very conveniently located downtown, and they have wireless internet!

In Punakha I stayed in the Wangdihopelri Hotel (I hope I got that right) which was a lovely collection of cottages, made all the more lovely because the sun finally made its appearance in force. I even had my own veranda, on which tea was served.

Here I met another Rebecca, Bhutan’s foremost expert on birdwatching, which, I learned, is quite a popular activity here. I saw a few birds. I think they were all ravens, the national bird.

But the best was in Paro. Kado’s sister has renovated an old farmhouse, which now serves as a guesthouse. It is wonderful, beautifully decorated, totally modern kitchen and bathroom, comfortable rooms.

It also has three outdoor tubs where the traditional bath is taken, warming the water with stones heated on an open fire. The tubs can be seen above. And, when in Rome…

The farmhouse, however, is hardly like a true Bhutanese farmhouse. In a traditional home, the kitchen is in the center of the house, with a stove that serves not only to cook but also to heat the building. There are no lights, so lights out is when the sun goes down.

There is often a formal sitting room in which to receive guests, decorated with colorful rugs and cloths, and strangely, plastic flowers.

The animals are kept on the ground floor or in stables just outside in the courtyard, while the family sleeps upstairs, the whole family, in one room, shoulder to shoulder. And then there’s the outhouse. I stayed in one of these homes in 2001, and although it was an interesting and unforgettable experience, I much prefer plumbing!

Traditional Bhutanese Medicine

2007-04-28T10:14:00.000-07:00

Thimphu town is not the only thing growing. The Institute for Traditional Medical Services began as a modest dispensary for herbal remedies formulated according to Buddhist traditions learned in Tibet. It has grown to include a hospital, a pharmacologic research unit, and a training center for traditional medicine doctors and clinical assistants.

I met Sonam Dorjee, one of the assistant research officers, and a very bright and creative man. He took me on a tour of the museum of traditional medicine and easily spouted off the Latin names of the plants used in their remedies.

He explained to me that there are plant, animal, and mineral components to the medicines, and these formulations are based on ancient texts. All of the components are Bhutanese, but they are unable to use the animal material because they cannot kill for use of their bodies. So, the ancient gurus have developed plant or mineral substitutes for the required animal ingredients. And the modern gurus use their laboratory to verify the claims. So far, everything has held up, according to Sonam.

Blue poppy has no opioids in it. The plant is evaluated in the lab, and any sort of steroid is removed before being used medicinally. The whole plant is dried and powdered then ingested. It is used to help speed healing of closed fractures.

Chinese caterpillar – one of the high value products. It is the final stage of the life cycle and is no longer considered “animal”. It is infected by a fungus, causes the caterpillar to burrow backward underground, and then the fungus grows out the caterpillar’s head and they live happily, symbiotically, ever after. It is used as an aphrodesiac.

This is the treatment room where steam/aroma therapy is performed, along with massage therapy.

Most of the ingredients are from high altitude, above 3500 meters. Local nomads who live at that altitude are hired to harvest the herbs. The nomads’ previous only form of income is from cows. Now they are being taught to cultivate the herbs, beginning with the most scarce, to prevent extinction.

There are auspicious days for everything, form planting to harvesting to treating. On the 8th day of every month on the lunar calendar there is a celebration for the blue Buddha. That day happened to be the day I was at the hospital. The students pray to the blue Buddha every day for guidance.

This is Dorji Wangchuk, Director of the Institute for Traditional Medical Services. He is very proud of the growth of research and implementation of Bhutanese medicine. He is also confident that traditional and modern medicine can coexist and learn from each other. He tells me it takes 5.5 years to train to be a traditional doctor, and that there is no shortage of interest among young Bhutanese students.

The philosophy of Bhutanese traditional medicine is not dissimilar from Indian ayurvedic chakkras and Chinese yin and yang. Based on five wheels and the balance of humors – air, bile, and phlegm, disease exists when there is imbalance. There are many charts and wheels illustrating how to maintain or restore balance. The practice of Bhutanese medicine is just as much spiritual as it is physical.

Kuzu Zangpo!

2007-04-27T11:04:00.000-07:00

These are exciting times for Bhutan. Several big events are taking place next year, and therefore many preparations need to be done now.

Next year marks the centennial of the monarchy in Bhutan. Interestingly, next year also will see the first parliamentary elections in the country. This past Saturday a nationwide mock election was held to inform people of the voting process, and to physically go through the motions to be sure there is no confusion. Just under 50% of registered voters turned out, and just about 50% of the eligible voters have registered. Some people felt the mock election was a waste of money, and in protest, didn’t vote. But the feeling is that when the time comes for the real election, there shouldn’t be a problem.

It was the fourth king’s desire to create a democratically elected parliament, to create a government run by elected officials. It appears his work is coming to fruition, and in celebration of that, he is stepping down, and handing the throne over to the crown prince. This has never happened before; the king reigned until his death. But I guess being king since the age of 17 in 1972 can wear you down a little.

So the coronation of the fifth king will take place next year as well.

One of the first things the new parliament will do will be to ratify the first constitution, which is being drafted right now. Peday is working with the chief justice on this project. She recently attended a workshop in South Africa on constitution drafting. During the workshop everyone introduced themselves, and she felt a little out of place because her country is to adopt a constitution as an act of peace, not in response to war.

Thumphu, as a result is growing, and fast! Maybe too fast? Traffic is becoming more and more congested, despite the continnued presence of this traffic cop.

Construction is going on everwhere.

A new, huge, 5-star hotel is going up downtown.

A new sports facility is being built.

There is even work being done around Memorial Chorten.

There is also a new fleet of city buses that look like something out of the '60's, decorated in bright colors and rainbows.

No new building permits have been issued, and all the work is supposed to be completed by next year. Hmm - next year might be a good time to visit...

Civil Aviation

2007-04-27T10:47:00.000-07:00

This may seem odd as my first official meeting, but, we were in Paro and the road was closed, and the Director General of Civil Aviation happens to be one of Kado's cousins.

He tells me of some important projects they are working on. Right now, the airport in Paro is the only one in the country. They are considering building one or two others in the east, for domestic flights, which would help both locals and tourists. As it is right now, crossing the country by car takes at least half a day, on narrow, treacherous roads. The airport would be a big improvement, but of course comes at a cost. There is a runway in either Mongar or Trashigang, I can't remember, but it is in no shape to actually function as a runway.

Already, Druk Air has grown since I was last here in 2001. At the time they only had two small crafts (one of which broke, literally, a piece fell off the wing – the one that was supposed to take me from Bangkok to Paro, and I had to be rerouted through Kathmandu and flown in on Buddha Air), and now they have the same two small crafts, which they lease to India and Thailand, and two new airbuses. I flew in on one of these new planes, and it was quite comfortable.

I also asked about helicopter travel, and this too is in the works. They have 17 heliports in the country, but no helicopters. When necessary, they lease choppers from other countries. Helicopters can be a tremendous help in transporting patients to the hospital from villages in the eastern part of the country. He agrees and he tells me the purposes of the helicopters would be commercial, search and rescue, and medical evacuation. I remember seeing patients three weeks after their injuries, because it took them that long to get to the hospital. Short of having more hospitals, helicopter transport would be a significant asset for patient care.

The rest of the conversation consisted of he two of them gaily bantering back and forth about which of them is the bigger playboy.

Road Safety

2007-04-27T09:24:00.000-07:00

This week is the First United Nations Global Road Safety Week. The irony. When I was here in 2001, one of the issues I was interested in exploring was the prevalence of motor vehicle accidents, and after driving on the one cross-country "highway" I understood the problem much more clearly. I don't know what the UN safety week entails, and I don't know how this is being promoted other than the signs that hang across the main street in Thumphu. There were no other such signs in the other towns.

Improvements are taking place on the roads. On the way to Punakha, I was pleasantly surprised to see that parts of the road had been widened, and PAVED! Along some stretches there were even guardrails. These improvements are slowly making their way east. I am a little concerned that this, while making travelling by car a bit easier, may actually cause an increase in the number of road traffic accidents as people start driving even faster around the unchanging hairpin curves.

Some of the work is more of a hassle than others. The road between Thimphu and Paro closes for periods of 60 - 90 minutes during the course of the day to allow work to take place. Which means, yes, if you miss the window of road opening, you're stuck. Unless of course, you're Col. Kado.

We raced to Paro to beat the road closures, and cheated a little by piggy-backing on the tail of the queens' father (red Land Cruiser with BHT plate). Hey, you do what you gotta do.

All these improvements are being done in preparation for some big events coming in 2008, which I will get to later.

Kado

2007-04-27T07:30:00.000-07:00

One of the things I love about Bhutan is seeing everyone in the national dress. Everyone looks so smart and sharp in their ghos (men) and kiras (women). Except Kado. He shows up at the airport in his khakis and Ray Bans looking like something out of Top Gun.

There's the official look! Kado Tshering is a colonel in the Bhutanese army, a royal body guard, and long-time friend of the fourth king, Jigme Singye Wangchuck. We met six years ago when I was a volunteer in Bhutan with Orthopaedics Overseas/Health Volunteers Overseas. He had brought his "cousin" to the orthopaedic clinic with a leg injury. We have been friends since then, and he has visited the United States on a number of occasions. His wife was ambassador to the UN and many of his seven children were/are being educated in the States.

His official royal duties will come to an end when he retires this July 1. But because three of his children are still in college, he has embarked upon a new enterprise, and along with his second son, Phuntsho Gayltshen, has started a travel agency called Aja Tours. They are a small company, and they pride themselves on personalized, customized tours. Phuntsho, incidentally, is married to Peday, with whom I drove across the country to Bumthang in 2001. (OK, actually, neither of us drove - no way I would have tackled that road!) She has since completed her studies in law in India, and has returned to Bhutan, working for the chief justice.

For this week, he is my personal body guard.

And to celebrate our friendship, we drink ara, read: moonshine. If the question ever comes up, refuse the egg.

I think he may have more cousins than I, both actual and fictional. And we imposed ourselves on many of them during the course of the week.

This cousin owns a shop in the airport, and left work to make lunch for us in his home the day I arrived.

We showed up at his cousin's house for tea and a visit with his elderly aunt. It turns out his cousin, Karma, seems to remember a lady Dr. Masai from the States who worked in Bhutan for quite some time, many years ago. Sounds like someone I might know...

On our way to Punakha we stopped at the army training base in Wangdi where we had lunch with his wife's brother, a major, and his wife. I think we stopped here because he needed his brother-in-law to help him figure out how to put on his gho.

In Paro we made ourselves at home at his daughter-in-law's sister's house. This was not complete freeloading, though. Her father, a diabetic, had just received a glucometer from the States and none of them could figure out how to use it. I am proud to say, that I, simple bone doctor, managed to figure it out and explain it to them.

Completely unannounced, we showed up at his niece's house in Paro. They were all glad to see him, and immediately brought out an entire meal, even though it was the middle of the afternoon.

The children benefitted from the visit though!

We even managed to visit briefly with his brother.

It seemed everywhere we went he had friends, underlings, admirers, etc. It was difficult to get anywhere, starting with getting out of the airport, because so many people wanted to shake his hand, salute him, say hello and thank you. He is a generous man, stopping frequently on the road to give people a lift, doing favors when possible, just trying to make things a little easier for others when he can. He is a big man with a big heart.

Arrival in Bhutan

2007-04-27T00:41:00.000-07:00

It is truly a miracle. A comedy of errors in what is becoming an all-too-familiar Becky blunder has landed me in Bhutan. From cancelled flights, to delayed flights, to nearly missing (2) flights, and catching the last flight out, I really thought I wasn't going to make it. Just in case anyone was considering trying to make three connections in three different countries all within a 15 our period, don't do it!

At least I flew business class on Druk Air into Bhutan. That would have been a good thing to have remembered as I stood in the economy line to check in at 4:30am in Bankok.

And then, I was sure I would have to get right back on the plane and turn around once I got to Bhutan because of all the trouble I was having securing a visa. When I landed, I still wasn't sure if I had one. So imagine my surprise when I was swiftly shuttled over to the Diplomats line at passport control in the airport in Paro. There waiting for me was my good friend Lt. Col. Kado Tshering of the Royal Bhutanese Army, with the national visa officer by his side. Visa? No problem!

And so the adventure continues...

Until Next Time

2007-04-23T09:01:00.000-07:00

Back in the Hong Kong airport. No, no shopping for me this time either. Not enough room left in the suitcase. Not enough money left. Not enough will power not to use credit. So, I’m just going to sit here and take advantage of their free wireless and gather my thoughts on the lessons learned in Wenzhou.

I’ve learned that with some practice I can learn to speak Chinese, chew with my mouth open, play badminton, and maybe even reconstruct some hands. I’ve learned that baby panda fur is soft. I’ve learned a little more about Chinese geography, which is a miracle. I’ve learned to carry tissues with me, always. I’ve learned that I can still drink with the best of them – well, that I already knew.

I’ve learned that the orthopaedic surgeons of the Second Affiliated Hospital of Wenzhou Medical College are intelligent, thoughtful, and talented doctors. Their depth of knowledge is considerable and their technical skills unsurpassed. They are dedicated to the education of their residents, and each other. I do not hesitate to say that I learned more from them than they from me on this particular tour of duty. (Maybe now that I know a little more about their needs and desires, I will be better able to contribute next time.) I also do not hesitate to call them my friends.

They have given me a new perspective on how to approach such problems as the mangled hand and complex wounds. They have also given me new resolve to be a better teacher. My students deserve it. My patients deserve it. And my students’ patients deserve it. I thank them for this more than anything. I think being in private practice in the States can sometimes make me forget that part of the Hippocratic oath, "I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow", and to do so to the best of my ability.

I’m off to Bangkok, and then to Bhutan tomorrow morning, where the adventures will continue. So, for the expedition in Wenzhou, China, this is

The End.

Farewell Dinner

2007-04-22T23:58:00.000-07:00

I cannot believe it’s almost over. I feel like we’ve only just begun, and now it’s almost time to leave. But of course, there has to be a party first. All the big wigs of the department of Orthopaedics took Jonathan and me out for dinner and drinks, or should I say, drinks and a snack.

These are the poster boys for alcohol dehydrogenase deficiency, Jonathan and Dr. Li.

They presented us each with a plaque in recognition of our efforts, and of the affiliation between Wenzhou Medical College and Health Volunteers Overseas.

I then said a few words of thanks – in Mandarin (thanks, Siegrid!). I heard the Canadian did it, so I of course had to follow suit. They said I did pretty well, and my Mandarin did not have to be further translated.

Yes, I had a cheat sheet, and boy did they have a chuckle when they got their hands on it later. What can I say? Wo shi Mei Guo ren! (I am an American!)

Dr. Chen seemed bent on pushing me to my beer-drinking limit, and Professor Tse insisted that we at least “taste” the local bamboo liqueur.

Notice who finished first!

I can’t remember the last time I chugged half a liter of beer, and I hope I never have to do it again. You’ll have to check somewhere else to see THAT picture.

But at the end of the evening, Professor Xu nodded to me, and proudly proclaimed, “Dr. Yu, you the man!” I think I’ll take that as a compliment.

A Day in the Life

2007-04-22T23:56:00.000-07:00

5:45am OK, maybe not every day. But almost.

6:00am Exercise, along with everyone else in the neighborhood.

Tai chi, calisthenics, swordplay, tennis, walking, stretching. I’ve never seen the one with the fans before. Can someone tell me why Chinese people walk backward to exercise? Do they know something I don’t? And by 7:00am, they’re done and the field is virtually empty.

7:30am Breakfast. Breakfast consisted of noodles or steamed buns, or congee, with warm soy milk or sweetened cow’s milk. These are two of the ladies who served us breakfast every morning. They remind me of the kitchen staff at my high school. I think breakfast may be my favorite meal of the day.

8:00am Nurses’ report followed by a review of the previous night’s surgeries. One morning Dr. Gao was in the OR and no one would sit in the chair in front of the computer. Not even Dr. Chen.

8:30am Ward rounds. Each team rolled the cart of charts from room to room, examining post-op and pre-op patients, changing dressings and looking at xrays. They have an ingenious way of storing the xrays – in a plastic bag under the mattress.

This brace was made to help maintain shoulder abduction to prevent contracture, and to help protect the skin graft in the axilla. He seemed much more comfortable in the brace. It costs about $100. Not so far off from our costs.

(Aside: plastic bags are used for EVERYthing. Obviously they are used in stores, but also to hold xrays instead of paper folders. They are also used literally as “doggie bags” for leftovers. The food goes directly into the bags, no box or Styrofoam container. Likewise they are used for take out, with the food (and drink!) going straight into the bag. I’ve never seen people drink ilk out of a plastic bag with a straw before.)

9:00am Clinic or OR

This cute girl handed us our scrubs every day, with one cap and one mask. She would always have a locker key for me in her pocket - one that was up high. She thinks I'm tall. Then we would put on a pair of OR slippers, essentially rubber flip-flops, and line our shoes up in a closet. And so the day would begin.

And that’s pretty much where the routine ended.

The afternoon activity varied depending on the caseload in the OR.

Dinner was always early, as early as 4:30pm one day (that was before the badminton).

And here I am, until the internet gets shut off at midnight. Life in China doesn't seem all that different from life at home, except that I do miss Monday afternoon happy hour.

Dr. Jiang

2007-04-22T20:08:00.000-07:00

I left Dr. Jiang for last, because I knew there would be something to add right up to the last minute. He was the one who greeted me at the airport when I arrived, and he is now the one taking me to the airport as I leave.

He has been a God-send, and I am afraid that perhaps he may have been “punished” for being able to speak English as well as he does. The other surgeons counted on him to translate for us, to accompany us to dinners, and to arrange our weekend excursions. This, on top of being “on-duty” every fourth night, where there is usually surgery going on all night. He sometimes even rearranged his clinical schedule to accomodate us. And he always did everything with a smile on his face, genuinely concerned that we were happy and taken care of. He may be diminutive in stature, but he is large of heart.

He is married. His wife is a pediatrician who also works at the Second Affiliated Hospital of Wenzhou Medical College. She is pregnant and due to deliver their child in about two months. Unfortunately, she has been confined to bed rest for the final three months, so I did not have the opportunity to meet her. That did not stop her from giving me a silk scarf as a gift. I look forward to meeting her, and their child, the next time around.

Three hand surgeons before "Clasped Hands" of Yandang Mountain.

Dr. Jiang asked me one day, on our way to the airport to go to Chengdu, what kind of life I wanted. It was a question I don’t really have the time to consider much. I could only say to him that I wanted a productive life, personally and professionally; to be able to contribute in some small way; to raise a happy and healthy family some day.

He clearly has been thinking about this, a lot. He would like to take his family and move to Tibet. He thinks it is the most beautiful place in the world, peaceful and carefree, although he has never actually been there. I asked if he wanted to practice medicine there, and he said no, just live, and enjoy the land with his wife and child. He at least is hoping that he may be assigned by the government to be a volunteer in Tibet for a year. I did not quite understand how this works, but I do hope he gets his chance.

Prior to leaving, I gave him a book on Tibetan history and stories, to prepare himself for the day that he gets to move to paradise, and live his dream.

More Pretty Pictures - Hangzhou

2007-04-22T09:57:00.000-07:00

To make up for the mangled hands, I give you the West Lake of Hangzhou. This was sort of a last minute decision to go for one night and one day just to see the lake. I would tell you something about Hangzhou, but I didn’t really learn anything about it. All I know is it is a five hour bus ride from Wenzhou, and it is a very, very popular place for tourists, from both near and far.

This is the three pools reflecting the moon. OK, you got me, it is actually the sun. Use your imagination!

This is kind of ironic, isn't it? I'm not sure if you can read the writing, but this is the Swastika Pavilion. The swastika is a Buddhist symbol for perfect virtues and merits.

All kinds of activity can be found going on around the lake: mahjong, cards, splashing around in fountains, and of course, wedding pictures. Everyone was out enjoying the good weather and each other's company.

The kids seemed to be having a particularly good time, like this brother and sister.

This woman had this picture taken several times, because she couldn't decide which hat she wanted to be wearing in the picture!

This area came to be used as a winemaking center during the Song dynasty. My ancestors, perhaps?

There are a number of blue and white peacocks on the grounds. These poor creatures are tortured by ceaseless yelling and clapping as the tourists try to get the birds to fan their feathers.

Watching the Chinese tourists throw their trash into the lake was particularly disturbing. It’s not just that the activity itself is such a gesture of disrespect, I don’t understand how they can do it. They are so excited to take pictures with the beautiful scenery, even fighting to get the best shot. Then as soon as they’re done, they toss their empty bottles and wrappers and cigarettes into the water. I guess this guy will never be out of a job.

Every now and then I would find a stretch of pathway that was seemingly devoid of any other human life. They were still clearly within earshot, though. But in these moments, I could really appreciate the beauty and serenity of the lake, and I could see why it was a favorite imperial retreat. I don’t think they used megaphones in the Song dynasty.

The bus ride itself was pretty great in itself. On the way home I sat on the upper level in the front looking out the window. The view of the countryside was peaceful and I could just sit back and relax and do nothing. But now that wouldn’t be like me to do nothing. So I worked my computer for 4 hours, but even that was relaxing. It’s a sickness, I know.

Mangled Hands

2007-04-22T07:16:00.000-07:00

I love poppies. The bright, vibrant colors just make me want to smile. I think they look happy. These poppies are growing in Flower Harbor Garden along the waters of Hangzhou's West Lake.

OK - I think the title of this entry should have been warning enough, and I hope the picture of the poppies shielded your eyes from immediate exposure to graphic images of hand injuries. Scroll at your own risk. I post these more as a reminder for me, of the fragility and vulnerability of human hands. I mean, they're just out there, all the time. And their importance to us is never fully appreciated, I don't think, until we lose them. Or lose just some function, even temporarily.

This young woman sustained this injury in a machine at a local factory. The xray is the initial injury film; the clinical images are after the first debride-ment. The small finger was amputated at that initial surgery. She returned to the OR with the plan of creating a groin flap, maintaining the head of the ring metacarpal for possible future toe-to-finger transfer. But after re-evaluation of the wound, it was decided it was too large, the wound was too severe, and the transfer would probably not add any significant function to her hand. The metacarpal was thus shortened, and the wound covered with split thickness skin grafts using a manual dermatome.

This next young man sustained possibly the worst injury short of an amputation. Actually, a sharp amputation would have been far better for him. The images are not the worst. On the palmar side, his skin had been completely avulsed, along with the median nerve and some of the flexor tendons. He was debrided, the bone provisional-ly stabilized with an external fixator, and the skin reapproximated as a biological dressing, with the plan for definitive coverage, to be determined later. If anyone wants to see those other images, just let me know.

These injuries happen EVERY day. I hear the Chinese government is trying to better monitor workplace injuries, but I don't know if that includes provisions to try to prevent them more effectively.

In a couple of days I leave for Bhutan, whose national flower is the rarely seen blue poppy. Right now I kind of miss the orange ones that grow at home.

Grand Rounds

2007-04-21T23:15:00.000-07:00

Grand rounds is held every Wednesday afternoon, and for the last three weeks it has started with one of our lectures. They are very attentive, even though they might not understand everything that we say. They ask thoughtful questions, and even copied our talks so they can review them later.

After the lecture, the residents present difficult pre-op or even post-op cases. (One of the residents, I swear, reminds me of Jason Bateman.) They give the history, and show xrays, CT scans, MRI’s, etc.

And then they bring the patient into the room for everyone, Professor Tse in particular, to examine.

They then carry on a lively discussion about the case, after which I get a brief summary in translation. Then they ask my opinion. I’m telling you, I had to dig DEEP to say something intelligent about hip dysplasia and scoliosis and failed fracture fixation under a successful free flap in an ankle. It was much better when they got to an elbow or a wrist. I was much more comfortable arguing with Professor Tse (former head of the department) about whether it was muscle or capsule or bone limiting a patient’s elbow range of motion.

But really, watching them have their discussion (since I couldn’t understand them) was rather entertaining. Chinese is a very expressive language, and they add animated body language to go with it. And I think asking my opinion was just a formality, because my answer almost invariably was no surgery; therapy; observation. I’m afraid they think I don’t like to operate. Problem is, they don’t have therapy the way we have therapy. That’s really not an option as a first line of treatment. The one time I actually did recommend surgery, they all voted against. Oh well…

One week after a couple spine cases were presented and discussed ad nauseum, Dr. Li, sitting behind me, yells out in a tone of voice I would have used myself, “Next…!”

Clinic

2007-04-21T22:43:00.000-07:00

The outpatient orthopaedic clinic is held every day. On the first floor they check in, or stop at the pharmacy on their way out. It looks just like a train station, with flashing lights and a board with some sort of “schedule” scrolling continuously. Controlled chaos, sort of.

Upstairs on the second floor, there is a large bulletin board with a picture of every orthopaedic surgeon, and the patients go to the board and choose the surgeon they wish to see. I don’t know if this is true, but they definitely look at the pictures on the board and do a lot of pointing.

They then line up outside the appropriate door, which is labeled hand surgery or trauma surgery or foot and ankle surgery, etc. But they don’t stay in a line, it’s more like an amoebic mass than a line, and whoever gets in the door first is seen. And once you get in, you have to hold the doctor’s attention, because there are other patients literally pushing through the door during your exam.

One day in the general clinic Dr. Li saw 80 patients. He wearily said, “Too many patients”, then exclaimed in exasperation, “Too many Chinese people!”

The clinic we go to with Dr. Gao is the VIP clinic. Patients pay 60 yuan per visit to this clinic, as opposed to the 10 yuan they pay to see a resident. And the “VIPs” here are no different from the ones at home. These are not the stoic Chinese patients I referred to earlier. And Dr. Gao has the patience of a saint.

One patient asked him for his phone number. He then asked her what good would it do her to have his number? She insisted and he conceded. I wonder if he gave her his real number. Apparently this is not uncommon.

We saw everything from post-op patients from various hand reconstructions, to pre-op patients for congenital anomalies, to post-traumatic deformities. There is also the occasional low back pain and breast reconstruction following mastectomy. I had no idea…

This little girl has an anterior interosseous nerve palsy, three months out from a supracondylar humerus fracture treated with traditional Chinese medicine.

This patient has a long-standing and slowly growing mass in the supraclavicular region that is tender to palpation. We have a little bet going on as to whether or not it is a nerve tumor. Unfortunately, she doesn’t want to have surgery just yet, so we’re going to have to settle the bet later.

This is follow-up from a Boutonniere correction we did two weeks ago. Still straight. Cases like this worry me here, because they do not have dedicated hand therapists – they don’t have much in the way of therapy at all (total knee and total hip patients are simply told to get out of bed the second day after surgery). Not only that, but follow-up is often sketchy. It amazes me that this patient returned to clinic. Then again, this is the VIP clinic.

Hey, that’s not a hand!

After Dr. Gao’s morning clinic on Wednesdays, he is treated to a wonderful lunch prepared for him by the nurses of the 12th floor. They do this just for him, and just on Wednesdays. Definitely better than the food in the OR! We all sit/stand around in the nurses room and eat. And they eat loudly! I mean, it takes effort to make that much noise with each bite. I remember now that it is a sign of appreciation for the food. I still need some practice, but I think I’m getting pretty good at it!

Food Do-Over

2007-04-21T01:18:00.000-07:00

Go back and reread the Food page.

Thank you to everyone who kindly pointed out to me the formatting problems on the Food page. I think I've fixed it, and improved the entry a little, added pictures from a few more meals. I hope it's better this time!

(I think I fixed a few other pages too, and would welcome any feedback.)

Dr. Chen

2007-04-20T23:37:00.000-07:00

Dr. Chen, standing to my left at Yandang Mountain, is like your cool young uncle. He's the one who laughs AT you when you do something stupid (thereby teaching you how to laugh at yourself), the one who goes on the roller coaster with you - twice, and the one who bought the beer when you were too young to do so yourself.

He has the greatest laugh and smile, but for some reason, it disappears as soon as a camera appears. He is so lively and animated, I would learn Chinese before coming back here again, just so I could understand his jokes - and he is joking ALL the time. I feel like I can almost understand him just by his gestures. He's the one who makes morning rounds and grand rounds tolerable. He is so obviously smart - I just know I am missing out on some learning because I can't understand what he says at these conferences. Everyone listens to him.

Here Dr. Chen is listening to Jonathan give his lecture on anatomy of the hand and wrist. He is LISTENING, and going through the range of motion demonstration - like he doesn't already know all of this forward and back. This is an example of his humility - he knows he might still pick up something here or there, no matter how long he's already been doing this. Between his cases he is always looking into other rooms, coming in to see what is going on, to give suggestions, or ask questions. In the OR, he will tie another surgeon's gown, or open sutures, or adjust the lights. He is willing to do whatever is needed to help things along. No task is too small. I love that.

So, cool young uncle here (who am I kidding? - he could be my little brother) - little brother here, is one of the chiefs of the division of hand surgery - and that's pretty cool, if you ask me.

It took a few bottles, but here is that smile I was talking about.

Something in the water?

2007-04-20T06:15:00.000-07:00

What is with all the duplicate thumbs??

And they span the whole range of Wassel classification types. Athough I have not seen a thumb triplication - yet.

These two cases are two different kids. With the exception of this OR sequence, all the images are of different kids. Maybe there IS something in the water! (No, Mom, I am NOT drinking the water!)

Even this kid is perplexed by his extra appendage.

Oh, look, I found a couple more that had surgery today:

This kid is going to be trouble - no matter how many thumbs he has!

More Follow-Up

2007-04-19T15:51:00.000-07:00

This is the patient whose wrist I scoped last week. Yes, he was still in the hospital when this picture was taken - post-op day 5. I am not sure why they stay in the hospital so long. For some, it is a matter of distance, for others it is a matter of pain control, but for most, I have no idea. What is even more perplexing, is that they are admitted to the hospital sometimes days before their operation. Sometimes they come in through the Emergency Room, and that I can understand. But others come in on their own or are admitted directly from the outpatient clinic, with no date or time for surgery scheduled yet. My theory is that they have them in-house so when there is OR time and available surgeons, they can do as many operations as possible, and having the patients in the hospital guarantees there will be available patients. That's my theory anyway.

As a token of his appreciation for doing his surgery, he gave me this beautiful bowl. His wrist pain is better (surgical placebo again?) and he did go home after this picture was taken.

A little homesick

2007-04-19T07:03:00.000-07:00

I would just about kill for some ice cream right now.

And a TV.

And Beeker.

I miss my washer and dryer. And I realize I am one of the lucky ones. I actually have a washing machine in my room - which works! And right outside my door is the rooftop which is strewn with lines for hanging clothes to dry. So I did my laundry the other day and hung the clothes out, and, you guessed it, it rained.

But what I'm really starving for is some sports. There is only so much of the smoking soccer players I can take. And by smoking I don't mean like "smokin' hot" smoking (although I suppose some of them could be; their calves certainly are). No I mean smoking as in cigarette smoking during the games! I guess they're not supposed to be using their hands anyway.

As if they read my mind, Dr. Li and some of the residents invited us out for some athletic activity - a friendly game of Badminton. I was thinking more along the lines of spectator sport, and baseball at that. But, I decided to go along to take pictures.

So off we went with Dr. Li, Dr. Jiang, Dr. Yu (not me), and Dr. Fei to the local club. They are fierce competitors! They sometimes play up to five hours at a time, but tonight we had the court for two.

I took a few shots, but my competitive spirit couldn't keep me out of the game for very long. It was fun. Dr. Li won every game. Well, except for that one where I was his partner. But he says I have good technique, and maybe even some talent. With some practice he thinks I could be a top-notch player! Somehow I just don't think learning badminton is going to make it onto my to-do list. But, I suppose one never knows...

Dr. Xu

2007-04-17T23:42:00.000-07:00

I don't know Dr. Xu very well. That, however, does not keep him from chastising me for not speaking Chinese. He is professor, and chief of the Department of Orthopaedics, and a spine surgeon.

This is a picture from the first day. He is standing to my left.

Since I've been here here has been to two spine conferences, one in Shanghai and one in Beijing.

Today, he was doing a discectomy and single level fusion.

Well, his residents were doing a discectomy and single level fusion and he was "supervising"!

It's good to be the chief!

The department of Orthopaedics has seven inpatient floors, two dedicated to hand surgery. Every subspecialty is represented: hand and microsurgery, spine, adult reconstruction, pediatrics, foot and ankle, sports, and trauma. Walking around the OR one morning I saw a knee scope, an ORIF of a proximal humerus fracture using a locking plate, an ORIF of a both bones forearm fracture, pinning of a pediatric supracondylar humerus fracture, correction of a duplicate thumb in a one-year-old, and a radial forearm flap, not to mention whatever case it was I was supposed to be doing with Dr. Gao. There are 18 OR's and 4 procedure rooms. There are 3 available C-arms, and 4 pairs of loops that are shared. They do not have a fluoroscan, which is the only thing I see missing. They run their operating rooms VERY efficiently. Turnover time is about three minutes, which includes the mopping. It is impressive.

There are about 50 surgeons in the department, not including the residents. There are two women, incidentally, one of whom is a hand/microsurgeon. Her name is Dr. Li, not related to the other Dr. Li. She is beautiful, and stylish, and although I have not had the chance to work with her directly, I'll bet she kicks ass in the OR.

Apparently there is going to be a party for us this week, a farewell sort of thing. And word got around to Dr. Xu that I am a "real Chinese". I think I'm in trouble...

Addendum: I'm going to have to speed things up a little in the OR. In the time it took me to release two syndactylous fingers that had been partially amputated from constriction band syndrome, Dr. Xu had fixed a C2 spinous process fracture (essentially he drilled two screws into the back of a guy's neck - thank God for people like him), and resected a T9 vertebra, the whole thing not just the body, for a tumor, placing a large titanium cage in its place. What the hell is wrong with me?!

Dr. Zhang

2007-04-17T22:51:00.000-07:00

Dr. Zhang Yu was my first point of contact in Wenzhou. He is, as everyone has proven to be, a remarkable person. Not only is he friendly and fun and a most welcoming host, he is a talented surgeon, and a thoughtful educator. His English is excellent, and conversations with him have been enlightening, on many subjects.

His specialty is Adult Reconstruction. He did an eighteen month fellowship in Ottawa (and is quick to point out that it included TWO winters!) in 2003-2004. He brought his whole family with him, which includes his wife who is a nephrologist, and his daughter who at the time was in the first grade, and thus getting a head-start on her English skills (they usually start learning English here in the 3rd grade). His wife is currently enrolled in a PhD program in Shanghai, returning home on the weekends, thereby leaving Dr. Zhang with his pre-teen daughter on his own. It turns out he gets a perk by having us here. He, as one of the official hosts, must entertain us, and on those evenings his daughter stays with his parents. Men...

This is Dr. Zhang doing a total hip with Jonathan assisting.

The patient had had his other hip done previously, and is quite pleased with it.

Dr. Zhang has some interesting thoughts about medical education and the process of finding a job and residency. Here, one must find a job before getting a residency, because where one does his or her residency is where the job is. Does that make sense? So - if I got a job in a rural hospital, those current surgeons would be my instructors. Surgeons are not trained at central university settings and then farmed out. Where you go is where you stay. Apparently forever. Therefore, there is no standard for residency training, and what and how much is learned during training varies from place to place. This is why there has been such variation in the type of care a patient receives at an outside hospital before transferring here.

That's not to say that he is completely thrilled about training at the universities either. At university settings such as the Medical College of Wenzhou, he feels the mechanism by which a physician or surgeon is promoted is outdated. Promotion is based on publication, without consideration of clinical productivity or educational contribution. He no longer reads the Chinese journals because he feels the Chinese scientific studies are not very good, and are published simply for promotional purposes. He reads JBJS. He has also been to Rosemont, IL twice for courses on total hip and total knee arthroplasty.

His practice in adult reconstruction is growing. Currently he does about 100 arthoplasties each year, and about 300 trauma cases each year. But he does not take trauma call - those are cases he is asked specifically to do. He feels the numbers will begin to switch soon, as Chinese people are becoming more accepting of these implants, as these, of course, would not be able to be removed unlike the trauma plates and screws.

Likewise, he feels Chinese patients are going to be seeking more elective surgical care for things like rotator cuff injuries and meniscal or cruciate ligament injuries. He is very proud of the department of Orthopaedics, and thinks it can be rounded out with a sports specialist, or at least with training of their current surgeons in more elective sports cases. I find him to be a forward-thinker, not only for his own practice, but also for his department, and the field of Orthopaedics in China. I think he will achieve his goals, both on a micro and macro scope, and I believe he will accomplish great things. They are lucky to have him.

And yes, there will be more entertaining before we leave!

Jiuzhaigou

2007-04-16T23:41:00.000-07:00

No, I did not take this picture.

Actually, our first stop was Munigou. I can’t tell you anything about it, because our so-called “English-speaking” guide could not speak a lick of English. You better believe I’m getting my money back.

Anyway, the falls are beautiful, and I’m sure there is some great story about Chinese history or philosophy that goes with it.

In any case, I can now see why Chinese painters painted mountains and waterfalls the way they did – they actually look like this.

Speaking of artists and their study of nature, I wonder if Constantin Brancusi ever saw Jiuzhaigou. There is a river called Lover’s River because of two rectangular stones that stand side by side, as if they were embracing. Sorry, I couldn’t get a good picture of it, but it looks kind of like this.

N.B. When planning a trip to Jiuzhaigou, which I do recommend, stay at the Sheraton! (I had to turn q2h to prevent bed sores.) Allow at least two days – the first to take a guided tour (an independently hired English-speaking guide costs 400 yuan) and the second to hike around on your own. September and October are the best times to go, and at that time Huang Long would be open, too, and apparently that is gorgeous.

Jiuzhaigou was beautiful, just as everyone in Wenzhou had told us. Interestingly, none of the people in Wenzhou who recommended going to Jiuzhaigou had ever been there.

It is said that one would not want to visit any other mountain after seeing Huangshan (I would agree with that), and that one would not want to visit any other waters after seeing Jiuzhaigou. The color and clarity of the waters were amazing, mesmerizing almost.

The name means Nine Villages Valley, as there are nine Tibetan villages in the valleys, which form the shape of a "Y". Three of the villages are open to visitors, and one in particular is like a carnival every day. The park opened in 1984 to tourists, and has since been named a Unesco World Natural Heritage site, as well as one of the world’s Man and the Biosphere Reserves.

After all our troubles with our non-English-speaking guide, we hired another guide on our own. Her name is Angel, a name given to her by her boyfriend, and she was indeed our angel that day. She was able to give us some explanations of what we were seeing, but more importantly, she was able to tell us where to go, when to get on a bus, and when to walk. We might still be on the mountain if it wasn’t for her.

Look at Angel’s handbag. At first I thought it was a cartoon of a panda head, but it is actually Tim Burton’s The Nightmare Before Christmas!

As we were walking around, it was funny to see Angel pull out her cell phone occasionally and take pictures. She lives here. She is a guide here. But, she tells me, she is usually on one of the buses that goes from stop to stop, giving explanations but not ever getting off the bus. She has only actually been out in the park a few times.

The Jet Li movie Hero was filmed here, at Arrow Bamboo Lake. I’m gong to have to go back and watch it again.

This is Panda Lake, so named because this is where the pandas come for water. Allegedly, six giant pandas live in Jiuzhaigou, but they are never seen because there are so many people here. I can’t even imagine what the crowds are like during the high season. I thought I was adept at navigating through a crowd, but I got nuthin’ on the Chinese. (You know, the real Chinese people). It really is a mentality of survival of the fittest, the quickest, the pushiest. And it appears the smaller you are, the better. I’m learning.

No, this is not one of the villagers. This is a Chinese tourist who is dressed up in a traditional Tibetan costume. How much do you want to bet she did not volunteer for this?! The colors are vibrant and beautiful. And the women were not the only ones playing!

This is Long Lake, the highest lake in the park. You’ll notice that there are no other tourists in these pictures. If only I had a soundtrack to play for you, because they are all, hundreds of them, standing only a few meters above us, loudly taking photographs. According to Angel, it is always this way, because the Chinese tourists are too lazy to walk down to this viewing platform, and therefore it is almost always empty, while the platform above is packed.

Pictures, at least pictures from ground-level taken without a wide-angle lens, do not do this place justice. And I don’t know how to line pictures up on this blog to give you a sense of its scale. Trust me – it is spectacular. Maybe this will give you some sense of the park’s grandeur.

The trees are bare and it is still quite cold. I can only imagine how beautiful the park is in the summer when the flowers are all in bloom, or when the fall foliage can be seen in all its splendor. But why imagine? I bought a book.

It was getting kind of frustrating trying to take pictures without a foreground subject (and I wasn’t about to be in every picture), then this very considerate little bird solved my problem. Visible wildlife was scarce that day. This bird, and another hiding in a thicket of thorns, a couple of ducks (hmmm, starting to remind me of a particular drinking game I used to play) and an occasional school of fish. No pandas.

We went to one of the Tibetan villages, called Shuzheng Village, which, as I mentioned, is more like a carnival than a real village.

At one point I was reminded of the shopping frenzy on the Ponte Vecchio in Florence. The "street" was lined with vendors all selling the same "Tibetan" goods.

We went into one "house" to see a typical kitchen - complete with TV and DVD player and, yep, there was a satellite dish outside. It was beautiful in a way, with all the bright colors and the prayer wheels and flags. But it was a little sad to see a culture become so commercialized and bastardized. This is especially so for me after having been to Bhutan which is also a Buddhist nation that celebrates with stupas and prayer flags.

In any case, these are prayer wheels. Inside and outside the wheels are written prayers, and each time the wheel is turned, the prayer is said. Sometimes these are placed in stupas that straddle a creek or stream so that the running water continuously turns the wheel. Likewise, the prayers that are written on the flags are "spoken" whenever the wind blows.

I'm saying a prayer for all of you.

Like the monk in leopard print?

The only thing that was truly authentic in the "village" is this little boy's smile.

Anyway, Jiuzhaigou is supposed to be known for its waters, so I will leave you with images of the blessed waters of the many lakes and falls.

Five Flowers Lake

Arrow Falls

Colorful Pool

Shuzheng Falls

Sparkling Cascades

And finally, this is a Tibetan wish of good luck to all. So I bid you all Ja Shi De Le.

Chengdu

2007-04-16T23:39:00.000-07:00

The first thing I see as I walk off the plane in Chengdu is this huge ad for Visa. Not funny.

Now that I have the pandas posted, I can tell you about the rest of the weekend.

We were picked up at the airport in a car that was permeated with the aroma of processed cannabis. Kevin, our guide, looks like he is about 14 years old. He is actually 22, and has been a tour guide for 2 years. His English is pretty good, but he confessed to us in the car that he was very nervous for some reason. We reassured him that he was doing great, but the poor guy was sweating profusely by the time we got to our destination.

Chengdu is the capital of Sichuan province, yes, the Sichuan of hot and spice Sichuan food. (We had their famous hot pot for dinner. More on that later, but here is a picture of it. There was definitely sweating and nose-blowing - using tissues - going on. My mouth is watering just looking at it.) Sichuan is located just east of Tibet, and is reportedly one of the most beautiful provinces in China.

If you recall, Wenzhou is located in the southest corner, in Zhejiang province, south of Shanghai. Chengdu is just below the center of this map.

Chengdu is a medium sized city of approximately 10 million. It is far more modern and developed than I had imagined. One of its streets is closed off to cars, and this is where they sell electronics, and there is no mistaking this street for anything else. Prada, Ralph Lauren, Ferragamo and other designer stores line the other main boulevards. But, as Kevin pointed out, the people move more slowly here, as this city, and most cities in the west, are much more laid back.

We wanted to buy silk while here in Chengdu, since it is, after all, on the silk route. We went to a silk factory where they tried (successfully) to get us to buy their wares. This is me holding a cocoon of live silkworms, and here we are demonstrating the strength of the silk. The merchandise was beautiful, and their sales techniques very slick.

But our first stop was the panda base, which I have already written about. Kevin told us he had just been to the Panda Base a few days before with a group of Australians. He likes their expressions “G’day, mate” and “No worries”, which sounded very cute coming from him. I asked him how often he comes to the Panda Base and he answered about once a month. I tell him he is very lucky. He agrees, but then points out that he has never been abroad. Point taken. I am very lucky, indeed.

I am in love...

2007-04-16T22:07:00.000-07:00

…with this little guy!

Can my smile be any bigger?! His name is Tian Fu (I totally made that up. Of course I don’t remember his real name. Tian Fu is the name of the main square in Chengdu and also the name of my hotel. So we’re going with that.)

He is 7 months old and weighs 17kg. They weigh in at only 100-150gms at birth! He is adorable, chewing away on his bamboo. He was warm and soft – the fur much softer than I anticipated, and hungry.

Look at the expression on his face when he dropped the bamboo while Jonathan was holding him. I was a little worried for a minute. But his caretaker came and took him away before any chaos ensued.

There are 62 giant pandas at the panda base, and a number of red pandas as well. They are at various stages of maturity, and right now there are 17 cubs, if I understood correctly. Much to my dismay, they were sleeping that afternoon, except for Tian Fu who they woke up to play with us.

Let’s look at him again.

I suddenly have a craving for Oreos.

He even posed for a group shot!

Giant pandas are so typically Chinese. Here, this guy had plenty of room to walk from point A to point B, but he insists on walking right over his sleeping compatriot. They are very social, even though in the wild they are solitary after the age of one and a half.

At the age of 4 or 5 they reach sexual maturity. Here at the panda base they try to encourage the pandas to find a mate naturally, but if that fails, well, they help things along, and apparently, it works!

This is Mei Mei's family tree. She was their model parent, who bore something like 12 cubs while at the Panda Base.

Other than sleeping, their main activity for the day is eating. They eat up to 14kg (can that be right?) of bamboo each day. The problem is that they do not digest most of it, and have to eat almost continuously to get the nutrition they need. Why they developed this diet for bamboo given their digestive capabilities is something the researchers here are trying to figure out.

For you hand surgeons out there, look how the panda holds the bamboo. He has a pseudo-thumb, a sort of sixth digit that has evolved so that they can do this. Pretty neat, that whole evolution thing.

This is a favorite spot - a scratching post.

There are also several red pandas here. These poor fellas always seem to take a back seat to their larger, rounder cousins. They're pretty cute, too!

Giant pandas have two wishes in life. The first is to find a way to get rid of the dark circles under their eyes. And the second, is for once, just once, to be able to take a picture in color. I did not make those up.

One more look at Tian Fu. I could die happy now.

(What are you looking at??)

Food

2007-04-13T08:51:00.000-07:00

I was in a hurry when this post was first created, so I did not really do it justice. I hope I've done better this time. Enjoy!

This is a wonderful type of restaurant in Wenzhou known as Tian Yi Jiao (I'm sure I'm butchering the spelling.). This is where you can go and choose your own fresh fish, or fowl, and they then cook it and serve it however you request. Along the side of the restaurant are the chefs, displaying their creations.

This is a delicious rice cake being deep fried in pig fat, which will then be sprinkled with sugar and served hot. Mmmm good!

And this of course, is the famous duck tongue. It is cured and quite tasty. I don't know what the tendril-like things are, but those I think are the best part. If anyone knows what that is, please don't tell me.

And here we are eating the final preparations. Soooo delicious!

Last night I found a night market close to the hospital. There were all kinds of people out, shopping, eating, putting their children on little coin-operated rides. The scene was festive - and yet this happens on a nightly basis.

This is the sugar cane cart, and the vendor is shaving the bark from the cane for these girls. He looked at me funny as I took his picture, and when I used mt universal excuse of "I'm American" he looked at me again. He thinks I'm beautiful, for an American, because I look a little Chinese. You know, a little around the eyes.

A couple of young guys were buying skewered foods from this gentleman. It smelled so good. He had all kinds of vegetables and seafood and raw meats that he cooked right on his cart, and then smothered them in hot sauce and spices. I couldn't resist. Even with all the delicious food I mentioned above, this was easily the best meal I've had so far. And it only cost me 50cents.

Eating on the streets is probably not the smartest thing to do here, but, you know, these days, not so smart. I haven't needed it yet, but, have Cipro, will travel!

When we had dinner with Dr. Zhang, he took us to a different sort of restaurant. You order by going to a display of food, sort of like the plastic renderings of dishes you find in Japan. It was very difficult to choose, since everything looked so good!

There were only three of us eating!

I'm jumping around a little, but since this is a redo, I am taking some liberties. In Jiuzhaigou the food was pretty awful. But there was always the option of keeping a stash of yak jerky on hand for emergencies.

In Chengdu we went out for their famous "hot pot". And let me tell you - it was HOT! and we ordered the medium level of hotness. Here is the pot.

Feeling a little warm? These are the things we cooked in it:

Oh, we started with some small intestine, and a little stomach;

And then we went on to the live catfish that fought vigorously being thrown into scorching spicy broth;

And then something I recognized - some vegetables. Thank goodness!

This is an internal organ from either a pig or a goat. I don't recommend it, whatever is it. And if anyone knows what exactly it is, I'm not so sure I want to know.

I am proud to say that, despite its prevalence, I have not had any McDonald's here. The Diet Coke, however, was an extremely fortunate find!

My Turn to Play Teacher

2007-04-12T23:07:00.000-07:00

Let me just review - since I've been here, we've done a couple of different rotation flaps, an anterolateral thigh flap, a groin flap, a free latissimus flap, and a few skin grafts. That isn't including all the replants and revascularizations that were done in the middle of the night without us. And all this time I have been watching, wide-eyed, trying to learn as much as possible.

Today, however, we finally stepped into my arena, and performed a wrist arthroscopy.

This is a gentleman we met in clinic last week. He is a police officer who injured his left wrist during an altercation, with complaints of ulnar sided wrist pain that has been getting progressively worse.

You can't really see the MRI well, but I just wanted to show you the very sophisticated system they have for maintaining patient charts. The patients carry their records themselves. But they don't just have the records, they have a card that you see in the credit card type slot under the monitor, which has all of their radiographic imaging, other study results, and their prescriptions. Pretty cool - except I had a hard time reading the wrist MRI upside down. More on the outpatient clinic later.

The wrist scope was challenging. They do not have an arthroscopy tower, but that's OK - neither did the county hospital when I started working there just three years ago. Problem was, they had no way of controlling or maintaining traction. I think you will be able to see in this series of pictures how the fingers are slowly slipping out of the (Chinese) finger traps as we lose traction across the wrist. They do have an arthroscope of the appropriate size, but most of the other instruments are taken from the knee set, and instrument choice is quite limited.

But we pressed on, and began with a diagnostic arthroscopy, which did reveal the suspected TFCC tear. In the midcarpal joint I tried to explain how the capitate and hamate together resembled the shape of buttocks. Didn't learn that word in Mandarin. But as I was trying to describe this, Dr. Gao blurts out, "Oh, baby's ass." And the conversation continues in Chinese with an occasional "baby's ass" thrown in.

Despite the battle to maintain traction, we managed to repair the TFCC with two outside-in sutures. The timing of the case was actually quite fortunate. Just last week Jonathan gave a lecture on the anatomy of the hand and wrist, and I gave one on wrist arthroscopy and arthroscopically treatable conditions.

We had a captive audience, which puzzled me somewhat as we did not have a translator for the lectures. They seemed to follow, however, and at the end asked questions. I showed a video on the outside-in TFCC repair technique (Thank you Dr. Edwards) and they actually asked me to replay it, pausing it at various times to ask more questions.

Jonathan gave another lecture this week on Fractures and Non-unions of the Scaphoid, and next week I will lecture on SLAC/SNAC Wrist and Basal Joint Arthritis. It is a pleasure speaking to this audience. It is clear that they wish to learn everything they can from us, and from whomever else with whom they should come into contact. I am glad to be able to reciprocate the teaching. I was beginning to feel a little guilty.

Fish Out of Water

2007-04-12T21:30:00.000-07:00

I am so obviously American. I don't know if it's my size or my volume, or maybe my iPod that gives it away the most. I feel like I should apologize to my mother. But then I think about my mother's behavior and I think maybe we should both be apologizing to our homeland.

A few nights ago we had ladies' night out, as I had three of the nurses take me out shopping. And there is a LOT of shopping to be done here. Stores are open until 10 or 11 at night, and it isn't until about 9pm that the city really comes to life. If any of you plan on coming here to take advantage of "Made in China", bring your MasterCard, because they don't take Visa!

This is a new upscale shopping mall that just opened here in January. They have beautiful things - the women in Wenzhou are quite fashionable - and the sales ladies actually wait on you, pulling things from the rack while you're trying things on. I felt a little like Julia Roberts, except I could hear Mrs. Wu, the head nurse, keep telling them, "No, the BIGGEST one you have."

It was a lot of fun, and no, you will not be seeing that necklace on me any time soon.

We went upstairs to the food court for a "snack". I told them just a light dinner, because I have been eating so much lately. This is what they consider a light dinner for 4: 5 entrees and an appetizer. How do they stay so small?!

So, it wouldn't be ladies' night if there wasn't some gossip. Both nurses on the far side of the table, Mrs. Wu on the right and the other whose name I PROMISE to learn tomorrow, are married with daughters aged 14 and 11 respectively. Kitty is single, but has a boyfriend who lives up north, near Beijing. She met him on-line, and still has yet to meet him. Dr. Jiang is a favorite among the ladies. He is about 5'2" (I think I'm being generous) but apparently his wife went after HIM, and everone thinks she is a lucky woman. Finally, they all have a little bit of a crush on a certain attending who I've written about. I'll give you a hint - it's not Dr. Gao!

Tonight I went out for a walk to get some "fresh" air. I did not exactly prepare well for this trip, as I still have not actually seen a map of the city (in English). So I chose a destination I was pretty confident I could find - the Olympic Hotel (There is a Puma store behind the hotel.) But no luck. I still got lost. So I went to ask for directions and what pops into my head? "Ou est l'hotel Olympic? C'est loin d'ici?" I don't speak French. Seriously, if I am going to suddenly be able to say something in a language I don't speak, why couldn't it be in Chinese?

Words that would have been good to learn before coming:
- Hospital
- Bathroom
- My address here (still don't know it)
- Doctor
- Where is...?
- How much is...?

I hate to admit it, but "I am American" works as an excuse for just about everything, and that's a sentence I did learn.

Follow-up

2007-04-12T06:16:00.000-07:00

I can't stand that I can't see my own blog! I thank all of you who have been kind enough to email me to tell me there have been no spelling or grammar errors yet, but you know I won't be satisfied until I see it myself. If you look again in a few weeks, you'll probably notice some changes - actually, you may not since they will probably be slight and subtle and you'd have to be as obsessive and anal as me to notice. So don't bother. Anyway...

Remember the first case I presented? The guy whose index finger we sacrificed to preserve his thumb? I won't put the injury pictures up again (even though I think those might be some of the most beautiful pictures I've taken so far) but I wanted to show you the finished product which you didn't get to see because Dr. Gao was hungry.

Isn't it beautiful? Almost looks like a regular hand.

A week later on rounds his dressing was taken down - and he wasn't so happy about that, although you couldn't tell by the laugh on his face.

And this is what it looks like now.

Americans!

2007-04-11T07:51:00.000-07:00

About a week ago, Jonanthan and I were walking toward the "hotel", when we passed two Caucasian men who commented on how good our English was. It turns out Matt and Kurt are PA students from Oregon, who are here on rotation for a month. Their school has 17 rotations abroad, and their students have been coming to Wenzhou for the last 5 years. Their mentor here, it turns out, is Dr. Hau, the gastroenterologist who had been our translator on the first day's opening ceremony, and at dinner with President Gu. (He also apparently is a huge fan of Prison Break.)

Last night we had dinner with them - Indian food. Naan! Really never thought I would actually miss bread. Passed on the rice. They have been far more adventurous than we. Kurt likes to walk randomly around the city, get lost, and then take a cab back to the hospital. Matt prefers to do the same, but by bus. They bought bicycles and have braved the Wenzhou streets to explore, covering more ground than they could on foot. They serendipitously found themselves on the outskirts of town, in a cemetery, during the celebration of Qing Ming - the Chinese version of Memorial Day. Families were out at the cemeteries burning paper money, eating, drinking, and celebrating.

After dinner they introduced us to a bar called La Luna, owned by an American named George, where internationals come gather, eat burgers and drink Budweiser. Passed on the Bud. Close to the bar is A-wang salon, a full service salon and massage paarlor.

It is awesome.

In the foreground Kurt is having his ears cleaned; behind him Matt is having his neck massaged; and in the background someone else is having his back walked on. There is a separate room for foot massages. They serve tea while you wait and even provide free internet access.

At 50-90 yuan for each spa service (roughly $6-$12), I can see how this can become a weekly habit. Something tells me I'm going to be back here again before leaving!

Two New Flaps

2007-04-10T23:34:00.000-07:00

This should be interesting. I am writing this from a computer in a massage parlor (more on that later) and after each word I type, it turns into something that resembles Arabic. Well, most of this will be in pictures anyway, so don't worry if you can't read this.

OK - with the text and this xray the gory pictures should not be on the page right away. The first patient is a 22 year old man who injured his right index finger in a machine at a factory.

He has full thickness skin loss volarly, with exposed (and distally avulsed) digital nerves, exposed flexor tendons, and a tuft fracture.

This was easily and matter-of-factly treated with a groin flap, which will remain in place for about three weeks.

The second patient is a 41 year old man who sustained a right femur fracture, tibia fracture, and ulna fracture in July 2006. He was treated at an outside institution with a plate on the ulna, a plate on the femur, a hybrid fixator on the tibia, which also required fasciotomies. Later he also underwent skin grafting. He has no active motion of the right ankle, and his foot is insensate. He adamantly refuses to have the leg amputated, and emphasizes that he has already spent over 200,000 yuan on his surgeries. He is quite invested in that leg.

So the injury was nine months ago. The tibia has not healed, nor for that matter has the femur or the ulna. The skin over the tibia can best be described as bark. He has returned to his home town of Wenzhou for definitive treatment. Before dealing with the nonuninion of the tibia, he will require better soft tissue coverage, and the plan was a free rectus or latissimus flap.

I know this is never routine, but even Dr. Gao needs to inspect, and think about how he is going to attack this problem.

To add to the complexity, he has lipomatosis, and has scars all over his body from multiple excisions. The decision was made to proceed with a free latissimus flap, which was relatively free from scars.

If you look at the far end of the incision, as the flap is being raised here, you can see one of the lipomas. We removed three in the course of raising the flap.

Here the flap is being raised. In the second picture you can see the pedicle on the left, and if you look closely, the long thoracic going to the serratus.

The flap is raised and the pedicle isolated. It is now ready for transfer. And...

It fits!

Here you can see both the arterial and the venous anatomosis in the posterior aspect of the knee. The tibial nerve is the larger structure above them.

Unfortunately, about 10 hours after surgery, the flap was found to be swollen and dusky with venous engorgement. Even more unfortunately, the on-call team, was already in the OR with another disaster! So, about 12 hours after surgery, the anastomosis was explored. The vein had clotted off. The ipsilateral lesser saphenous vein was harvested, but found to be embolic! Approximately 8cm of the contralateral lesser saphenous was then harvested, and 4cm used as a vein graft. (The remaining 4cm of vein was left in the wound - just in case.) The flap pinked up, and we're all keeping our fingers crossed.

Well, all of us except the first patient.

Wenzhou Weekly Routine

2007-04-09T23:02:00.000-07:00

I am so definitely going on a diet as soon as I get home.

Tonight we partook in a Wenzhou tradition. It may not be isolated to Wenzhou, but here it is definitely part of the routine. Dr. Zhang took Jonathan and me out for dinner, which was of course fantastic, and fantastically filling. After dinner he treated us to an hourlong foot massage. So far, after each dinner out, someone has offered to take us out for a massage, and until tonight we have declined. Apparently, people here do this every week, sometimes twice a week, and for some it is part of their activities of daily living.

It began with a foot bath. Actually it began with the usual stunned expression and exclamation of disbelief, "Huh? they don't speak Chinese? They look Chinese!" Then came the foot bath. We soaked our feet in hot water mixed with date powder which felt like the softest, lightest sand, and the bottom of the small wooden tub had an uneven surface so the massage could begin even before the therapist entered the room. Then came a short shoulder rub, and I could hear my therapist remarking on all the knots in my upper back. We then settled back for the foot massage, fat ankles and all, watching CCTV 9, in English! He might deny it, but Jonathan fell asleep!

At the end the therapist shook my legs out to relax them, but as he picked them up by my feet he exclaimed to Dr. Zhang, Wow - it didn't look like it but her legs are heavy! I'd like to think it is because of the dense muscle mass I've been building up walking up five freakin' flights of stairs at least twice a day!

To do list:
1. Call Jenny...

Yandang Mountain

2007-04-09T17:36:00.000-07:00

Yesterday was Easter Sunday, and we went to a church of a different kind. Yandang Mountain is more grand than any cathedral I've ever been in, with stunning natural beauty (and a few man-made amenities) and fresh air - which we welcomed after a week in the city and the hospital. Drs. Chen and Jiang accompanied us to the mountain, where we were met by Lucia, our guide. I hope this counts as going to Mass - there was a temple after all.

If you look closely, you can see that in between the two rocks is a building. There is a nine story Buddhist temple built right into the rock, complete with golden Buddhas and Guanyins.

The smell of incense burning certainly added to the spiritual feeling of the mountain. There were 407 steps to climb, just to get to the bottom of the temple, and Lucia did this in heels! The views were spectacular.

If I understood correctly, China has 58 designated natural beauty sites, and Zhejiang province has 3, one of which is Yandang Mountain. We watched as a performer demonstrated how Chinese herbs were once gathered from the sides of these monolithic rocks, by rappelling down its face. It was a little difficult to watch him do this - there was definitely no net!

The many rocks have been described as resembling images that have religious or secular meaning to the Chinese. The image in a particular rock can change depending on one's vantage point, and sometimes depending on the time of day. (A separate entrance fee is charged to see the "night view".) This is an idea described well before the sculptors of the modern period emphasized the totality of a particular piece, often without a designated "front" or "back". The ability to completely appreciate a "sculpture" by being able to walk all the way around it was recognized here long ago. Here are some examples of the imagery.

This is a bear, going to get some honey.

This is a tiny outcropping, but of course resembles Buddha, welcoming visitors to the temple.

The rock on the right is a young woman, facing away from the rock on the left, which I assume is the man who pissed her off. Looks to me like she might be growing a little hair on her chest.

The rooftop you see at the bottom of the picture is a nunnery, where the nuns live and care for abandoned orphans. Behind the nunnery is the head of an elephant facing right. You can just see his head, an eye, and the top of his trunk. And behind the elephant you see five fingers, representing an open palm - safety and security.

I would personally like to know exactly which Chinese herbs had been taken in order to come up with all of these!

The rocks are not the only things that invoke the imagination. We went to see two waterfalls, the Big Dragon Waterfall and the Little Dragon Waterfall. There was not much water falling as there had not been any recent heavy rains. But with the smaller volume of falling water at the Big Dragon fall, the swimming dragon could make his appearance.

I think this one is my favorite. It was mesmerizing, watching the shape of the "dragon" change continuously.

This is a tour group from Shanghai, recognized by the distinct Shanghainese dialect. They are climbing up the side of the mountain, to get a view of one rock that resembles a phallus, which the Chinese like to refer to as the "root of life". We skipped it.

Not worth the effort. How many jokes can I make?

Oops - sorry. It's Easter.

Wenzhou, China

2007-04-09T00:23:00.000-07:00

Soccer players have really nice calves. I realized this today as I sat down on the field to stretch after my run, and started to watch some of the games going on around me. Nice vantage point. I never noticed this before. Am I allowed to write that here?

Anyway, so now that I've been here for over a week, let me orient you.

Wenzhou is located on the southeast coast of China, about two-thirds of the way up from Hong Kong toward Shanghai, in the Zhejiang province. Hangzhou is probably the most famous city in this province, known for the famous West Lake.

It is a "small" city of 7.8 million people, and was one of the earliest coastal cities to open up economically. It remains one of the ten most economically important cities in China.

The city is divided by a river, much like Paris and Montreal. It even has its own Ile de la Cite in Jiangxin Island.

Its main industries include manufacturing of plastics, glass, small motor parts, and leather. (They say leather, but all the factories I passed on the way in from the airport I swear said Synthetic Leather.) This, of course, helps to explain the number and type of hand injuries seen here. Here is an interesting fact: many Wenzhou-nese(?) travel to Italy to live and work in the leather shoe and clothing industry. They sometimes spend as much as a year at a time there. I figure, since pretty much everything is made in China and Italy, if I limit my shopping to these countries, I could save myself some serious money.

Wenzhou is a city like any other big city, with large corporate buildings, mostly banks, stores and restaurants.

The homes are found tucked behind the modern buidings along the large boulevards, down small side street and alleyways. These are homes seen from behind, from the rooftop of my "hotel". An ever present image is the laundry being hung out to dry from windows and balconies.

Just like in other big cities, traffic can be a problem. It is an even bigger problem when painted lines are ignored, and cars share lanes with buses, motorcycles, bicycles, tricycles, and pedestrians. Crossing the street has been an adventure. I am not sure what has served me better, living in New York City for six years, or all the Frogger I used to play as a kid.

One of my favorite things to find in a new city is the street market. We stumbled upon this one, near the hospital, on Saturday morning.

I think a whole million of the 7.8 were there that morning, buying fruits and vegetables, cured meats, "fresh" poultry, and fish.

I'm not sure what the pool tables are there for.

This is the bamboo shoot lady. She uses an old fashioned scale to weigh her merchandise, and after payment, she offers to peel the bark for her patron, using a cleaver that will keep the hand surgeons in business, even if all industry should fail.

Here is another tool invented by hand surgeons used to seed pineapples.

In the end we found the market to be the perfect place to buy breakfast.

As a city girl, I think I could get used to this place.

Eating, eating, and more eating

2007-04-08T23:31:00.000-07:00

Had dinner last night at Dr. Gao's house. We met his wife and son, and his brother and niece who were in town. He lives in a two-floor apartment behind a huge KFC. It is at the top of six flights of stairs, which is what his wife had to walk up with all the meat and produce for last night's dinner, which was enough to feed an army. His family is very nice, and his son, who is 17, is considering attending university in the US. He is very shy but his English is quite good, demonstrated only because his parents forced him to translate all through dinner. It was cute - they clearly have a very close relationship. Mrs. Gao, after cooking up a storm, was later thrilled to be able to show us old family photographs. I'm sure Dr. Gao was equally thrilled.
That's Dr. Jiang, me, Mrs. Gao, Gao's son (whose name I can not spell), Dr. Gao, and Jonathan. Between last night's dinner and today's lunch, we ate more than I usually eat in a week. At lunch today, each new dish was placed on the lazy susan and spun to me. And until I served myself, no one else could eat. But there were just so many dishes! I thought that maybe if I just kept gnawing at my pig's knuckle, they would just keep spinning the lazy susan, but no such luck. The bamboo shoots and shark's lip landed right in front of me and was going nowhere until I took some. (Yes, that was shark's LIP - rather unique texture, if any of you are interested.)

So, Mom, no need to worry. I'm being well fed. (And I'm not drinking the water, or eating the raw vegetables, or the pre-peeled fruit - OK, maybe the watermelon...) Serious dieting to begin the second I get home. More on the food later...

Dr. Li

2007-04-07T23:51:00.000-07:00

I realize the title of this post is "Dr. Li" but I feel I need to give you a point for comparison. This is Dr. Gao holding up a University of California, San Francisco T-shirt. He is such a goofball. With his animated gestures and demonstrative expressions, he reminds me a little bit of my father, especially how he rests his hands on his belly as if it were a shelf. On first meeting Dr. Li, I found him to be Dr. Gao's polar opposite.

Dr. Li is in the middle of this picture with the red turtleneck on. This is his typical countenance, serious, all business. If Dr. Gao demonstrated economy of movement in the OR, Dr. Li practices economy of speech. There is not a superfluous word in his statements, and every statement has a point. I feel like I should be taking notes when he speaks. OK, I confess, I actually have been taking notes.

In the beginning I was kind of afraid of Dr. Li. He reminded me of all the professors I have had in my training who I somehow disappointed. I may be paranoid, but I could swear they would look at me and shake their heads, thinking, *sigh* Beck, you could have been so much more. (To which I would now respond - if I were more, I probably would not have the time to be doing this.) Dr. Li looks at me whenever I say anything, and kind of furrows his brow. I hope it is because he just didn't understand my English, and not because he's thinking, Huh? What the hell are you talking about?

I think he is a brilliant man. Every aspect of his surgeries is carefully considered, including the possible reconstructive options that he is leaving himself for the future. There is a reason for every step he takes. His experience with microsurgery is vast. He did an elective study period in Tsing Tao (yes, like the beer) where most of the patients injure their hands in the noodle making factories. He performed a replant or a free flap about three times a week. Here in Wenzhou, the mechanism is also factory work, plastics, small motor parts, synthetic leather. No injury ever takes him by surprise him anymore.

I never really know what to say to Dr. Li. He doesn't make small talk, and I feel like I struggle to come up with intelligent questions worthy of his consideration. So imagine my surprise when I hear he is going to be joining Jonathan, myself and Dr. Jiang (no need to use his Americanized name anymore) to Jiangxin Island today for a little sightseeing. What are we going to talk about??

It turns out Dr. Li is a very sweet and friendly man, and intelligent beyond medicine and microsurgery. He gave me a brief description of how the Chinese characters were designed 3000 years ago, that they are not just random lines and marks, that they have meaning not just in a word but in their actual appearance as well. We also had an interesting discussion about religion. He does not practice Buddhism as a religion, but considers himself Buddhist, culturally. He explained the four gods/winds/spirits, one of whom holds a dragon as a symbol of tolerance, instructing us not to be stubborn but to be open-minded. We discussed the similarities among several different religions, and he thinks it is our stubbornness that prevents us from recognizing these similarities, and accepting that the differences are simply varying expressions of faith.

Happy Easter, by the way.

I also discovered that he can have fun, too. It was nice to see him outside the hospital, smiling and having a good time. And no, we never did get the kite to fly.

Old hat?

2007-04-07T23:05:00.000-07:00

I have had a request to put the gory pictures at the bottom of the page, but if I did that, then the story wouldn't make much sense. So instead, I'm going to try to give you at least enough text so that the picture doesn't show up right away when you open the blog. Is it working so far? I'm sorry, but I still can't view it myself, so I have no way of knowing. Enough stalling? This is your gory picture warning...

So far, almost everything I've seen here in the OR I'm seeing for the first time. They do these microsurgical cases on such a regular basis that it's become routine for them. I feel like I'm getting an extension on my fellowship. Jonathan is certainly getting a huge head start on his. Here is an example.

This gentleman sustained a crush injury to his right thumb which resulted in a proximal phalanx fracture and a soft tissue defect that left his thumb extensor tendons exposed.
The wound was debrided and the plan is to cover it with a lateral femoral fasciocutaneous free flap. Oh, yeah, sure - I do those every day.

The flap was designed, but in the process of dissection, the pedicle was found to be much more lateral than usual, so the flap needed to be redesigned. No big deal, new design, perfect flap.

The pedicle is isolated, anastamosis is performed under the microscope, connecting the artery, two veins, and a sensory nerve to boot.

And here is the flap in place, and although it may be hard to appreciate in this picture, it was pink and healthy when all was said and done. And it was done, just in time for lunch.

Next case - cubital tunnel syndrome, scheduled for decompression and anterior ulnar nerve transposition. Thank God! Here is one that at least makes it onto my surgery schedule on a regular basis. So this they give me to do.

And everything starts out just fine. The nerve seems a bit large and inflamed, but clinically he had significant neuropathy, so it's not really unexpected. The dissection continues to go along just fine, but just distal to the cubital tunnel I run into this:

What IS that?! It looks like an intraneural mass, but it turns out to be a ganglion cyst arising from the elbow joint. The ulnar nerve was so scarred down from a previous fracture (supracondylar?) that it had become more or less fixed and the cyst grew right into it. It clearly pierced the nerve and was not simply enveloping it. And so we continue with our string of "firsts". (Believe it or not, the next morning, the patient said he had more feeling in his fingers, he was able to abduct and adduct his fingers, although weakly, and he could almost cross his fingers. This, after dissecting his nerve apart completely. I personally believe this is a case of surgical placebo. But the fact that his nerve was functioning at all was a miracle.)

The day ended with some debridements, and I will spare you those photographs because they even make me a bit queasy. But here, as at home, the residents are performing the debridement while their trusted attending hangs out in the background. I suppose Dr. Gao would be able to say truthfully "I was present for the entire procedure."

Pretty Pictures

2007-04-07T16:48:00.001-07:00

I figured I've grossed you out enough for now. These pictures were taken on Jiangxin Island, an island in the middle of the river in the middle of the city. It was a nice, warm day (finally), though still somewhat hazy. We strolled the length of the island, tried (and failed) to fly a kite, and generally enjoyed a relaxing and peaceful day. Neither Dr. Jiang nor Dr. Li had to go into the hospital today, and they said so with such relief that I wondered if under normal circumstances they would have. We asked them how much vacation time they get, to which they responded "What means 'vacation'?" They get no vacation, and leisurely days like this are special. We were their excuse for getting out of the house, so Dr. Li very kindly invited us to "come back again any time!"

Come on - it qualifies as a pretty picture!

Short Round

2007-04-06T22:41:00.000-07:00

Chinese babies are so cute. And no, I'm not biased. This little boy with a perfectly round face had one little piggy too many on his right foot. But even that extra little toe was cute.

So we took him to the operating room and removed the toe. As he was waking up from general anesthesia, he was still a bit disoriented (dissociated?), but rather than crying from pain or the lack of a familiar face, he tried to eat the oxygen mask. It was adorable. I wish I could show you a video.

So maybe he still had some anesthesia on board which might explain the lack of crying right after the procedure. But explain to me why there was still no crying today, post-op day 1. He had pulled his dressing off, and was smiling and laughing (until the camera came out, of course).

I know there is the belief that Chinese patients are stoic, and it is probably true for the most part, relative to other ethnicities. But can this apply to children as well? How are they able to control their response to pain, or is it that their perception of pain is different? When I was a volunteer in Bhutan in 2001 with Orthopaedics Overseas, I noticed the same thing about the Bhutanese children. During dressing changes, which had to be painful, they watched, and maybe grimaced, but did not pull away or cry out. And after the dressing came off, they looked at their wounds with curiosity.

Kind of like this little girl. She is 3 years old and burned her hand in scalding water. Her burns were treated with a Z-plasty for the index finger, and full thickness skin grafts for the long and ring fingers, which were pinned to protect the grafts.

She checks out her hand, turning it over one way then the other. In fact, there was another little boy in the room who was being seen for a split hand, who starteed checking out her hand, too, and she held it out for him to have a better look.

And this is my favorite part. Not only does she not mind looking at her hand, and seems to have no complaints of pain, she does her own therapy at home, wiggling each finger individually with her other hand. Explain that to me.

Fat Ankles

2007-04-06T21:55:00.000-07:00

My brother once lovingly told me during my fragile adolescent years that my only skinny parts were my ankles. Not so anymore. I am guessing they use a lot of salt in the food here. Must increase water intake. Maybe decrease the beer intake. OK, well, increase water intake anyway. Sorry, was that a little too much information?

Speaking of beverages, look at what I found today -

I had to get out of the hospital for a while today, so I left Jonathan to plate a tibia fracture with the residents and I went for a walk. A few blocks away I spotted a green awning. It wasn't Starbucks but it still said "Coffee". One cup and my nagging little headache was miraculously gone. Laura, I wish I had heeded your foresight and left room in my suitcase for that French press you gave me! The chocolate is helping though! Lesson learned...

Well, maybe. I tried to go without coffee once before, during my residency. It was, in fact, after a trip to Asia, and I thought maybe all I needed in the morning was a hot drink. So when I got home, I substituted tea for my usual morning coffee. About halfway through our first total hip replacement on my first day back, I started bitching and moaning, and it came out that I hadn't had any coffee. My attending left the OR while I closed, and when I got to the recovery room he had a large cup of coffee waiting for me. And he warned me never to experiment with my morning routine on his OR day! I guess I don't learn so good. But I digress...

I can't access my blog.

2007-04-06T15:41:00.000-07:00

This is most annoying. For those of you who are familiar with my type A personality (which some would diagnose as OCD) you know how much it is killing me that I can't look at the page and edit, check spelling, adjust layout, make it pretty. Alas, I will continue to post blindly. My apologies in advance.

Morning Teaching Rounds

2007-04-05T22:33:00.000-07:00

I am continually inspired by the teaching that goes on here. The professors are dedicated, to their patients and their students. The residents are attentive and diligent in their work. It does not matter how long they have been in the program (John - whose last name is Jiang, and therefore easily Americanized to John - is in his 8th year of "residency". Becoming an attending is not clearly defined by time, and he recognizes that there is ever more for him to learn under the tutelage of Drs. Gao, Li, and Chen), they go to lectures, to the OR - even if they themselves are not operating, and truly try to learn something new every day. They scramble to get all the work done, running around like we do. But when it comes time for teaching, no one is ever in a hurry. No one is in such a rush that they can not stop to answer a patient's question, examine a hand, or look at an xray. They are thoughtful in both their questions and their answers. They have discussions, not pimping sessions where the object of the game is to humiliate. It is inspiring. I wish I understood Chinese.

Every morning begins with rounds where one of the floor nurses presents the new patients who were admitted to the ward the night before. She gives the history and current status. If surgery was performed, the on-duty surgeon describes the procedure and the rationale for doing whatever was done. Everyone then gathers around the computer to see what was done. You will be grateful that I spared you a close up of what is being discussed in the second picture here. This is a particularly useful practice, because some of the trauma that comes in is so complex, that at the time of surgery, the second stage and the third stage have already been planned out. The thought process is fascinating. By reviewing the overall plan right at the beginning, everyone is then on the same page.

Every now and then one of the residents presents a lecture after the cases are reviewed. Today was one such day, and the topic was hand allograft transplantation. I could not understand the lecture, but I was concerned that maybe this was going to be on our OR schedule. No, that was not the plan. In fact, they have never done a hand transplant here at this hospital. We had an interesting discussion yesterday about attitudes toward limb loss, and the differences between Chinese and American patients. We determined that the Chinese are much more reluctant to let go of a limb, even a finger, and so I asked if many patients who lose their hands ask for a transplant. The answer was yes, many patients do, which then begs the question, Why haven't they done any here?

Dr. Gao tells me that of all the hand transplants ever done, over half have been done in China, just not here. This morning's lecture reviewed not only the history of hand allografts and the technical aspects of the surgery, but also the cost and the psychological aspects as well. It requires dangerous immunosuppression, strict patient compliance, and a whole lot of luck. The hand transplant patient is not really a problem for the surgeon. We have the skills and the know-how to perform the procedure perfectly. This patient becomes a problem for the internist, to manage the medications and the psychological acceptance of having someone else's hand. So even though we have the technology (and God knows they put that technology to work here), the philosophy here is, it's not worth it. Transplantation of a kidney or a liver is justifiable, because this can save a patient's life. Transplantation of a hand may save a patient's limb, but may ultimately cost him his life, physically or mentally. When I first arrived, I was a bit concerned that their superior microsurgical skills had them looking for nails to hit with that hammer. Clearly that is not the case, and after getting to know the doctors over the last few days, I am kind of ashamed that I ever had that thought.

Oops.

2007-04-05T16:17:00.000-07:00

I forgot the official pictures on the "Official Stuff" post...

The Official Stuff

2007-04-05T06:17:00.000-07:00

Is this not the most ridiculous thing you've ever seen? When we walked into the hospital the first day, there was this huge banner welcoming Dr. Alan Giachino. I laughed and couldn't wait to give him a hard time. Little did I know that the banner would be changed by the time we left the hospital.

So the first morning we were ushered into a nice, large conference room which had been set up with a computer and projector and a power point presentation about the Second Affilitated Hospital of Wenzhou Medical College, and Dr. Gao took it upon himself to correct the spelling error in the title slide. Nurses from the neonatal department at Northwestern University were also visiting, and coincidentaylly arrived on the same day. All the department directors were there to greet us, and welcome us to their hospital.

The hospital has 1620 beds (which is often filled to >100% capacity), sees 1.4 million outpatients, 365,000 emergency patients, performs 21,000 in-patient surgeries, and 18,000 outpatient surgeries each year. It makes me tired just writing it down. They have a comprehensive department of orthopaedics, including hand surgery, spine, trauma, arthroplasty, foot & ankle, and sports. After obstetrics, the hand surgery division performs the most procedures per year.

After the formal welcome and description of the Hospital, President Gu congratulated us on choosing to volunteer our time to share what we know with them. He believes volunteering benefits not only those on the receiving end of our time and knowledge, but also the volunteers themselves, as work like this feeds the soul in a way that our normal daily work simply can not. It is his hope that more and more physicians, in all different fields of practice, will continue to volunteer to spend time with them here in Wenzhou.

So after we all had a good laugh over the banner, we decided to take a picture of all of us behind it.

(That's Dr. Zhang to our right, and Dr. Xu, Dr. Chen, and Dr. Gao to our left.) But it wasn't so easy. In fact it took quite a while because this lady stood right in front of the banner, reading it out loud, slowly.

She kept looking up at our hosts and asking incredulously, "Where are these American doctors? I want to see them!" They assured her that we were coming, but made no effort to point us out to her. This is one time when being a Twinkie definitely came in handy!

Mom would be proud

2007-04-04T20:28:00.000-07:00

Well, I think I did it. I've fulfilled my duties as an ambassador from the US. They are all very impressed with how well I hold my alcohol. We were invited to dinner tonight by President Gu and various heads of divisions in the department of orthopaedics. And as I downed my drink with each toast, they all seemed a bit stunned, but Dr. Gao assured them - she's a real Chinese; she can drink! Here we are after many maaaanyy bottles of beer.

Top row: John, Our translator and full-time gastroenterologist, the former head of the department of orthopaedics, the chief of orthopaedic trauma, Dr. Chen, Dr. Gao.
Bottom row: Jonathan, President Gu (formerly a nephrologist), me, and the department mother hen
It's really not fair. Even though they all wear nametags around the hospital, I can't cheat and learn their names by looking at them!

Gory Picture Warning

2007-04-03T23:38:00.000-07:00

The funniest thing I saw today, and that I've seen so far, was Dr. Gao walking out of the men's locker room with his white coat on, his socks and slippers, but no pants! Was I supposed to say something?

But just let me say this again, and this may become my daily anthem, Dr. Gao rocks. A 22 year old woman got her dominant index finger caught in a machine today, resulting in a partial degloving injury. All I can say is, she is lucky she lives in China. Dr. Gao fixed her in a way that I never even would have imagined. My plastics colleagues are probably going to look at this and say "of course we would have thought of that". Well, not me.

He took this

And turned it into this

using this - covering the defect, and restoring the nailbed so she'll have a fingernail as well! I would venture to say that in many places she would have been lucky if her finger wasn't immediately amputated. I know it was gross, but you can't say I didn't warn you.

So today I scrubbed into my first case, to assist with a rotational flap for a lateral ankle defect in an 8 year old. I'm glad I was able to share my expertise on this particular case, seeing as I don't do kids (unless specifically asked), I don't do ankles (unless they're broken), and I don't do flaps (hardly ever). I really got to show off today! I guess that means the only way to go now is up!

Dr. Gao

2007-04-02T21:52:00.000-07:00

OK - so today was our first official day and there were a lot of official goings-on. Formal welcome, meet the president, yada yada yada. I will give you all those formalities maybe tomorrow. Right now I feel compelled to tell you about Dr. Gao.

From left to right are Dr. Chen, Dr. Gao, John (whose last name I will learn tomorrow), and Dr. Zhang. From the moment I met Dr. Gao he seemed to be the mad scientist/nutty professor type. His hair looks as if he stopped believing in combs, his shirts stained with food, but an ever present grin on his face. Hmm, kind of reminds me of a certain professor I once had in my training. Between lunch and dinner yesterday he spilled his drink twice. He smokes like a chimney (did I mention he is the director of hand and microsurgery?). I know he slept well last night because when we saw him first thing this morning, it looked like his head had remained in one position all night. I won't even get into what it was like watching him eat breakfast. He had no idea what time his surgery was starting, so he decided to take us on a tour of the hospital.

But then, once he got into the OR, there was a transformation. This is a 33 year old man who sustained this crush injury to his left hand a week ago. He had undergone one debridement already, and pinning of the index finger fractures. The plan today is to amputate the index finger, and use the dorsal skin as a pedicle flap to preserve the thumb.

Debridement began with the biggest knife I've ever seen. I think I'll be ordering some No.23 blades for my future debridements. His movements were swift and efficient, easily debriding all dead and devitalized and expendable tissue. A benefit of having intimate knowledge of the anatomy involved.

But when it came time to isolate the pedicle, his movements became slow, deliberate, and precise. He sat up straight (something I can not seem to be able to get my residents to do), his 4x loupes fixated on his subject, and his great big bear paws steady. The flap was raised and tunnelled in mere minutes, it seemed. It was a thing of beauty. It's not that this was a particularly difficult case, but the precision and the economy of movement was truly impressive.

I apologize that I do not have a picture of the finished product right now, but after Dr. Gao transferred the first dorsal interosseous muscle and placed the first few key stitches, he left the rest to his vice professor. He took his gown off, his scrubs hanging out over his belly, and said, "Let's have lunch!" And when a man like that says let's eat, you eat!

Arrival in Wenzhou

2007-04-02T20:41:00.000-07:00

I arrived in Wenzhou yesterday without a hitch. The flight from Hong Kong to Wenzhou was only 90 minutes and I was met at the airport by John, a junior attending who just finished his training in hand surgery in Shanghai last year. He is from a town about 100km from Wenzhou, and his English is quite good. He tells me it is actually easier for him to understand English than the Wenzhou dialect, even though he grew up not too far from here. We went to lunch at this wonderful restaurant, which seemed to be the size of an entire city block, where every party has its own private room. (I discover later that this apparently is the norm.) We were joined by Professor Gao, one of the directors of the hand service, and a rather jolly man. We dined on Wenzhou specialties which included cured chicken, raw crab, and a warm smoothie made from corn. Quite tasty, I must admit.

I was then taken to my "hotel", the graduate student housing on the campus of the Wenzhou Medical College. I have a penthouse suite - not so desirable when one considers it is a five floor walk-up. It is simple and clean with plenty of space. Outside my window is a track and tennis courts and groups of students playing soccer. So much for my excuse for not working out this month.

After settling in, unpacking and organizing my drawer full of cords and chargers and adapters for my various electronics, a quick nap revved me up for more Wenzhou culinary delicacies. Remember what I said about duck tongue? Well, that was one of the evening's appetizers. Wisely, my hosts waited until I tried it, and liked it, before telling me what it was. At dinner I met Dr. Zhang Yu, an arthroplasty specialist who has been my point of communication until now, Dr. Chen, the other director of the hand service, Mrs. Wu, the head nurse on one of the hand surgery inpatient floors, and Kitty, a junior nurse, whose Chinese name means "flower bud". Dr. Gao joined us as well. Dinner was fun and lively, despite the language barrier. There was one phrase they all were sure I knew - Gam bei! And it would have been rude for me not to. I could tell they all enjoyed each other's company, and I am sure this makes for easy and pleasant days at work.

Jonathan arrived late last night. Jonathan is a 4th year Orthopaedic resident at UCSF, who is planning on continuing his training with a fellowship in hand and upper extremity surgery. I think this will be an exceptional experience for him at this time in his training. Hell, it's going to be an exceptional experience for me at this point in my career. It all begins in the morning...

Hong Kong

2007-04-02T19:34:00.000-07:00

This is a picture of Uncle Jimmy on my right, Uncle Rene and Auntie Julie, in their fabulous flat in central Hong Kong. It was nice to see them again, albeit briefly. Trying to do this in Cyrillic now. Not fair to do this to a novice blogger!

Testing

2007-04-02T19:30:00.000-07:00

For some reason, all the blogging instructions have turned into Chinese characters, with no option to switch back to English. Ergo, testing...

Free wi-fi in Hong Kong, but not in SFO

2007-04-01T10:07:00.000-07:00

Note to self - must allow for more time at the airport in Hong Kong. The shopping is unbelievable! Unfortunately, or fortunately I suppose, no time this time around. Uncle Jimmy took me to the airport this morning, and as I left him and cleared security, I was beginning to lament my lack of snacks for the flight. When what to my wondering eyes should appear? Aji Ichiban! I am now stocked with preserved plums and dried cuttlefish and duck tongue for the month. OK, I passed on the duck tongue.

I am looking forward to meeting Dr. Zhang Yu who is coming to pick me up at the airport. He will be my contact person, translator, cruise director, etc while in Wenzhou. I hear from Dr. Alan Giachino, who preceded me in Wenzhou and is the OO site director, that I couldn't ask for a more hospitable and generous host. Stress level slowly improving...

Almost there...

2007-03-31T07:23:00.000-07:00

14 hours, 22 minutes, 7285 miles, and across the international date line - I'm here in Hong Kong. I think I'm going to have to start upgrading. My dear Auntie Julie and Uncle Rene have graciously agreed to put me up (put up with me?) for the night. Uncle Jimmy and Auntie Rosina came over to join us for dinner, and tomorrow morning I'm off to China. Now, it's time for bed...

2007-03-25T21:49:00.000-07:00

Preparations

2007-03-24T23:24:00.000-07:00

It is late, and I am trying to mentally prepare myself for my trip to Wenzhou, China, through Orthopaedics Overseas/Health Volunteers Overseas. I leave Friday 3/30/07. I anticipate an exciting, rewarding experience, working with the physicians at the Second Affiliated Hospital of Wenzhou. I hope you enjoy following my work, and learning along with me.