Patience

Oscar and I scrub for team Go Global ... look at our uniforms :-)

Oscar and I are both making the same point here .... look at our hands :-)

We have completed one week of surgery training here in Darkhan. As with previous adventures, the bumps in the road have taught us the most and clarified our goals for the next week. Mostly, it’s about patience ….

There is an urgency in the way our trainees are operating. Quick movements, impatient transitions between tasks, dogged focus on small portions of a goal …. we can work with that, but they need to make some changes.

Oscar and I have repeatedly emphasized that by slowing things down, they will actually be more effective with their movements and ultimately more efficient at completing the operation. We have pointed out the tension planes and more effective ways of retracting. We have repeatedly shifted their focus away from one detail to addressing the bigger operation as a whole. We have emphasized the safe places to work toward the more difficult parts of the case. We have repeated these mantras over and over in hopes that when we leave, they will still hear our voices guiding them through when they are faced with more difficult operations.

Our nursing team has found the same – shortcuts to decrease turn over times ended up being inappropriate solutions that we were able to address. The three hours we spent separating all the instruments and creating new sets will ultimately save them time and be more effective for their continuation of the laparoscopic program.

So here we are, venturing into week two in Darkhan, Mongolia conquering quick movements, impatient transitions, and dogged focus on small details with Patience. It is not lost on me that there is a bigger lesson there. Not lost at all ….

Thursday Night

Bulga, one of the surgeons we are training here in Darkhan, arranged a trip to a ger for our team Thursday night. The pictures tell the story best. I could not capture the night sky as we left but that one is etched in my memory. 

JQ and Eric modeling Mongolian fashion

Eric drinking milk team 

Our hostesses at the door of the ger

Chad trying to teach me to ride

Jump

Team Photo

Bulga sang for us

Okoo and JQ

Mongolian Sunrise

I am in the middle of training for a triathlon. When I signed on for my fourth Mongolian adventure, I was a bit concerned about my training suffering from long days, poor diet, and lack of access to exercise.  My friend and trainer extraordinaire, Cari Bjelajac, sent me off with a jump rope and a supply of Juice Plus+ (as vegetables are hard to come by in this land of mutton). And I gave myself a break in my training schedule – just in case.

Though I cannot swim or bike for these two weeks, I have found a great running trail that tracks straight through a park full of silly statues, children’s amusement park rides, and up a hill to a city monument and a Buddha. When you get to the top of the hill, the sunrise view over the city is pure Mongolia.

Chad and I set out the first day and it has now become the 6am team tradition. We walk over behind the dilapidated stadium track and turf soccer field and off I run while my team enjoys the stroll. In the crisp air with the inspiring sunrise, these short runs are the perfect way to start our days in Darkhan.

Mongolia: Take 4

Air China flies LAX to Beijing at 2am …. I’ve been on that flight three times in the last 12 months.  There is no way to mince words on this one, it is a miserable flight. LAX is all but shut down when you arrive through security. There are no restaurants open to distract you as your body screams for your bed and a nice pillow. But alas, you have the fuselage to lean against for the next 12 hours of leg cramped travel.

So I jumped on that flight again last Sunday for my fourth trip to Mongolia. Fourth trip. Mongolia. I will again come clean, I never envisioned myself writing those words. Ever.  Call me crazy, but here I am.

We arrived in Ulan Bataar without incident and were greeted by Enkhe and Chuck and take-out Hazaara Indian food. JQ and I immediately, and aggressively attacked the Naan, butter chicken, and curry lentils right there in the parking lot of the Chingiss Khan airport – no shame, no pride, curry dripping down my chin. Ahead was a 4 hour bus ride to Darkhan and two long weeks of nothing but protein bars – the naan had to be conquered while it was still warm.

This year, most of our team is new to Mongolia. JQ and I know the drill and have grand plans to keep everything on track. My co-surgeon Oscar from Toronto (via Columbia) has significant international experience in tele-mentoring. Peggy from St. Louis is a nurse who has built a hernia surgery project in the Dominican from the ground up. Chad from North Dakota is a tech rep who has done previous work setting up telemed in Haiti. And Eric is a medical student from Salt Lake going into radiology.

Once that naan was history, we learned that Peggy would be delayed one day. We set off on the bus to Darkhan with plans for her to join us the following day. And at the end of our bus ride, we learned that we had only one translator for our time here – and that he was also the surgeon we were to be training … thankfully, the next day we got Peggy and the final two last minute additions to our team Okoo and Undush our translators, Mongolian life navigators and mother hens. With a complete team, we are set to teach some surgery, make some friends, and have some truly memorable Mongolian adventures.

Oscar, Eric, Tulga, Chad, JQ in front of the Hospital

Oscar, Chad, JQ, Eric and the OR

Mongolian Sunset

Mongolian Queen

I was given this very special gift from the Choibalsan team as I left Mongolia this year. Mongolian women have a respected place in this strong culture and I was incredibly honored to receive this doll. I recommend Jack Weatherford's book "The Secret History of the Mongol Queens" for additional reading on how women helped save Genghis Khan's empire. 

Clapping in the O.R.?

Returning to Choibalsan to work with this team again was truly a joy and a privilege. It was encouraging to see how much the team had learned – in technical skill and in surgical judgment. It was a pleasure to return to a somewhat familiar environment in such a far away land. It was a privilege to work with our friends and colleagues from our last visit.

I took a special pleasure in learning that one silly little thing I had done last time I was in Choibalsan, has become routine here in the operating room. The first time we were teaching here, I used to clap and cheer whenever the gallbladder was finally freed from the gallbladder fossa. I think surgery is fun and I think finding those moments of small victory are worth celebrating. Okay, it’s silly, but somehow, it has stuck. The first day of our trip this year, the operating team cheered raucously after the first gallbladder was released from the gallbladder fossa – and I laughed in shock. They then informed me that they do that for every cholecystectomy … every one.

If the legacy I have left in Choibalsan is the ability to celebrate the small victories – well I am more than fine with that. Cheers to my friends in Mongolia who do their job well and do their job with joy. 

Like a Prayer

The last time we were in Choibalsan, as part of our training program, we introduced the WHO surgical checklist and emphasized the importance of the “surgical timeout.” This short verbalization of the operative game plan introduces the patient, the procedure, and any known issues or potential areas of concern. The “timeout” serves to put the whole operating team on the same page. It is a moment of pause before you carry on with serious business, and sometimes, can be almost, like a prayer.

During this trip, we were happy to learn that the Choibalsan team had adopted the “time out” for all of their procedures. We brought additional translated copies of the WHO surgical checklist for the new operating rooms and started to teach the concept of the “debrief.” I am sure our star students will adopt this practice as well as they have the timeout.

(I encourage anyone who is interested in global health to read Atwul Gawande’s book The Checklist Manifesto)