• What Hurts The Most

    Dearest readers,

    Last night I sat alone in a midnight blur. I was surprised to find myself silently crying, somewhat despairing at the thought of a patient I had met earlier in the day. There was a sadness within me I had not felt for the longest time, an inexplicable heartache that I could not ignore. A woman in her fifties, with striking resemblances to my own mother, was wheeled into our clinic in a makeshift wheelchair, pushed lovingly by her husband, followed by a dedicated grandson, no more than six years old. Her hands had the slightest tremor and her facial expression was vacant, her eyes blinking and gaze blanking into the distance.

    Her story was simple. Two years ago the woman fell and hurt her leg but was still able to continue walking as normal, albeit with some residual pain. Her injuries were not too severe. However, to relieve her mild symptoms, she would buy painkillers from her local town’s pharmacy. Over the course of weeks, and then months, and then years, she noticed herself getting weaker, not stronger. She developed muscular aches and lethargy, more pains in her hips, more bruising of her skin, more swelling in her face. Her weakness had progressed so far she could now only get by in a wheelchair. She was now complaining of severe difficulties.

    X-rays were taken of her hips by our centre, showing barely visible bones – the spheres of her hip joints disappearing into darkness. It became clear from just watching her and reviewing her x-rays that she had likely been sold steroids from the pharmacy. And so when I asked to see her medications, her grandson, much like my little nephew, proudly pulled out a neat packet of her medications. The tablets were lovingly (and surprisingly) organised into neat compartments, and when I saw the little white steroid tablet this woman had been taking for years, a deep, unfamiliar stab penetrated my heart. This poor patient, in the hope of relieving her pain, had been slowly and sadly poisoning herself with drugs to the point of life threatening debilitation. This circumstance was only as a result of miseducation, disinformation and a health system that had failed her and her family. This is not an uncommon event in Cambodia, for steroids are truly available by the bucket load, but this particular story, whilst remembering my own mother, hurt me deeper than expected and last night, as I tried to fathom my feelings, I discovered now what hurts the most.

    We all suffer hurt at different and defining moments in our lives, changing us forever in ways we will often never understand. When these moments of pain arrive, we, as beautiful individuals, each palpate our pains differently, reacting to the noxious stimuli in a combination of instinctive and learned ways. From the physical hurt of a fractured bone to the internal pains of a breaking organ, we either cry out in despair or hold back the tears, bite our lips and watch as our wounds develop, forming the scars that appear slowly on the outsides and insides of our skin.

    The grief of emotional trauma often form the longest scars, both visibly opaque and yet clearly invisible within us. The emotional scars run through the entirety of our inner core and outer sphere, dictating which way we turn when challenged, which words we scream out when anguished, how tightly we close our eyes when we are already in darkness and in which moments we decide to let the tears flow past the barricades of our eyes’ resolve.

    As healthcare workers, our pain thresholds often take a specific pattern, for we are continually exposed to the physical and emotional pain of others on a daily, if not hourly basis. It is not surprising our own reactions get numbed, as we are drip fed psychological anaesthesia to move on to the next patient, and the next case, without accumulating the burdens that come from consulting and treating fellow humans in pain.

    As a child, I remember the times I would feel the loneliest, the saddest and the most vulnerable. It was the times when I felt out of control, when events were beyond me, events that I could not influence, that I could not change, that left me so overwhelmed and despondent. From the tragic disasters and sadness in the news, to the passing of loved ones, I would cry at the hopelessness of all that was out of my reach. I still remember sinking into a stupor after reading the diary of Anne Frank when I was eleven years old, so overwhelmed I could not go back in time to prevent this incalculable injustice of my new friend.

    And yet now into the middle of life, those feelings of sadness and despair when faced with a situation out of my control have largely disappeared. Perhaps it is our growing experiences in life that help put perspective on our pain, for I did not feel such personal hurt during my work in Haiti, when in the blink of an earthquake, thousands lost their lives and millions lost their loved ones. And in Pakistan, I did not personally feel the hurt of those displaced millions, losing their homes to the rivers of floods that swept down the nation. Or in Cambodia, and Myanmar, interacting with those bright eyed people that were soon to lose their lives to cancer did not open scars that had not already formed within me.

    Now I have realised what truly hurts the most. It is not horrendous outcomes of situations where we out of control, like an earthquake, or a flood, or a rare diagnosis of cancer – but situations when injustices occur to people where we are in control, when mistakes could be minimised, when man-made disasters could and should have been avoided. As healthcare professionals, we take an even deeper burden of this responsibility, to ensure we do no harm, at all times, at all events, for all of our patients. This patient, so reminiscent of my mother, so dedicated to the medicines prescribed to her, should not have been to the point where her life is at risk, simply by getting poor medical advice.

    Similarly, in our small surgical centre, often providing life changing operations, we should uphold the enormous burden to prevent easily avoidable mistakes in our own practice, to minimise the complications we may encounter, to eliminate any harm we may cause. In the short period of time I am here in Cambodia, I can only hope to implement safer practices to our surgery, in an attempt to gain back control in seemingly uncontrollable environments, to ensure at least our standards are robust, even if there are pitfalls elsewhere. Most human errors can be curtailed with an open heart, good communication and a willingness to improve – a mantra I explain to my colleagues each day – that talking to each other is free of charge, performing safer surgery costs no extra to plan and prepare in advance. I truly want to ensure we are doing the best with the free tools we have, to ensure that we do not hurt our patients and the people of this country, to not replicate mistakes made by others, and deep down, not hurt each other in the process, for I do no want to feel this pain each night in Cambodia.

    With love always,
    Saqib

  • The Temple of Surgery and The Checklist Prayer

    Dearest readers,

    Pchum Ben is a national religious festival in Cambodia – a time when families pay their respects to their dearly departed – those relatives that walked the earth before us, those who lived, laughed, cried and prayed in an era when we were not necessarily present. The ceremony involves the offering of food from the living to the dead, as the ghosts of bygone relatives temporarily waken from their perceived existence in the magical worlds beyond ours. Food is prepared and transferred via monks, acting as intermediaries between the donor and recipient in the confines of the temples and pagodas, the religious houses of worship in the community.

    Pagodas are architecturally quaint – a tiered tower with numerous eaves and hanging rooftops. They are often used to store sacred relics and scriptures of Buddhism and are revered locations where people gather, pray and find their peace. And like all religious houses, from mosques to churches and from synagogues to gudwaras, pagodas exude calmness and cleanliness, whilst simultaneously adhering to strict cultural rituals, rules and codes of conduct.

    Our hospital closes every year for a week in respect of the Pchum Ben festival, allowing staff an opportunity to spend time with their loved ones, near, far or further distant still. And during this year’s closure, with some personal energy, the hospital funded a refurbishment too of its most sacred room – the operating theatre. Surgery too, I believe is a metaphorical form of religion, with a worldwide cult following and a mixed mantra of ancient and modern scriptures combining science, art and hope.

    The operating room, like all religious houses, must follow a strict guide of practice. From dress code to the opening and closing of doors, from cleaning schedules to the correct positioning of vital equipment, every facet must be adhered to with fastidious, delicate care, like they too were sacred relics.

    The operating room staff, from surgeons, anaesthetists, nurses, technicians and maintenance staff must too treat the room like a temple, assigned guardianship of this hallowed room in which they are the monks that navigate and guide worshipers safely in and out of this temple.

    And the patients, often in Cambodia with little understanding of their own complex ailments let alone the science around surgical treatment, will come to this small surgical centre, in hope and prayer that their suffering can be alleviated. They are the true worshippers of this religion of surgery, believing there maybe cure within the temple of the surgeon. Their faith in surgery is the most enshrined of all trusts between humans, willingly becoming anaesthetised and powerless, whilst asking another human to help them.

    The World Health Organisation recently published a safe surgery checklist – a list of important safety measures that a surgical team should comply with, prior to and after performing every operation. It’s adoption was sluggish even in many developed countries but has now been recognised as an essential aspect of performing surgery and most surgical teams in the UK would feel naked without it. It’s uptake in low and middle and income countries has been equally difficult where other complicated factors often mean the safe surgery checklist is neglected or only paid with unwilling lip service. However, in this comparison with surgery as a religion, the checklist too is the dedicated prayer, the harmonious coming together of the theatre practitioners before and after surgery, to repeat and recycle the ascribed phrases and sentences, to ensure the patient has a safe passage through their procedure.

    With the new operating room completed, in its bright and shining glow, I have been urging all hospital staff to treat the room like the sanctuary of a pagoda, to be it’s guardian, to maintain its protocols and standards, and to ensure safety of our patients at all times, paying the same respect to them as they pay in faith to us.

    With love always,
    Saqib

    The new operating room in development, brighter, lighter and calmer:

  • Same Same But Different

    Dearest Readers,

    Phnom Penh is changing at an incalculable rate. It is evolving so quickly that even from my last visit four years ago, I barely recognise the streets I once shuffled my well-worn sandals through. Now the streets of my old neighbourhood are proudly adorned with a new facade of artistic, stylish restaurants and a collection of boutique coffee shops. Bigger buildings and prime real estate positions are now occupied by logos of branded international chains. Indeed, the very apartment from which I am writing this letter is situated between Domino’s Pizza on one corner and Starbucks on the other, both institutions newly arriving since I was last here.

    Walking through the streets was once a crazy game of avoiding high speed motos and low speed tuk tuks that whiz on by, but now one has to also avoid the multitude of 4×4 vehicles and saloon cars, bumping and grinding into each other in the already minimal gaps left between the pedestrians and motorcycles. The cars are old and dusty, but rarely one may see an outrageous display of wealth when a Bentley, Hummer or Rolls Royce honks its way through the traffic, demanding attention and right of passage.

    The skyline too is becoming unrecognisable, tall and taller buildings are popping up like a troop of grey and cream mushrooms in a smoggy sky, with many immature mushrooms still cladded in green tarp, waiting to ripen in the sun and soon be ready for human habitation. Each day the clunking and clattering of bare chested builders fill the noisy air whilst from morning til dusk, heavy construction machinery grind into your dreams, waking you up earlier than you had hoped.

    The night sky is beautiful from my rooftop, as the incessant activity of the streets below is sparked into colourful animation by flashing lights from the buildings, monuments and large digital billboards, frantically advertising Cambodia’s latest products and services. The road junctions now have traffic lights, blissfully ignored by experienced Phnom Penh drivers.

    But despite the changes, there is much about Phnom Penh that is the same. The early morning gongs of the temples – designed to be a traditional alarm clock for pious monks – still dominate over all other noises. The old wooden coconut carts are still pulled through the potholed streets by weary sellers and there are still makeshift fruit markets on many corners, displaying the colourful array of South East Asian produce that are in season currently. There are still mopeds carrying entire families – a husband, a wife with two younger children in between them and another toddler balanced expertly and finely on the handle bars.

    Beyond the changing skyline and new facade, underneath it all, it seems the lives of the people in the city have remained static since I was last here. The same tuk tuk drivers I once knew still occupy their designated corners as four years ago, easily recognising us upon our return to the neighbourhood, waving and shrieking loudly and happy to see us. Within the restaurants are the same waiters, only four years older, working the same shift, over and over, day and night, seven days a week. I was humbled and reminded how privileged my life has been when one restaurant waiter, working the same monotonous shift, remembered my old apartment address, including the exact door number of my flat – a meaningless fact I had forgotten long ago, whilst I was away enjoying my recent and rich experiences all over the world.

    And the hospital remains similar to when I left, the staff and patients very much the same. The poor still come to this small charitable surgical hospital, unable to afford the rising costs of surgery in the government or private hospitals, whilst others come having already been bankrupted by previous surgical care elsewhere. The cases remain as neglected and extremely heartbreaking as I remember.

    Since I have returned, one young woman has presented with a tumour on her face so large she has gradually become blind in both eyes and now struggling to breathe. Another woman, working as a farmer for many years, now in her forties, presented with a neglected club foot, never seeking treatment before for her severely misshapen foot. She said she did not get married because of the deformity and is now finding life difficult. I asked why she was seeking treatment now so late, “because this surgical centre is here”, she replied.

    I enquired if correcting the foot would help now with her relationship prospects, “No, it’s too late for that”, she sighed, “but I want to be out of pain”.

    There is a popular phrase that is said here in South East Asia: “same same but different”. Although there is no true definition of this catchy phrase, it is often used when describing something that may appear to be different but ultimately is the same. When I left the surgical centre in 2013, I left a soft toy of a cute monkey with my name badge pinned on its chest in the clinic room in a symbolic gesture to tell the staff I was still there with them. When I returned, I noticed that same soft toy, hanging in the same place as where I left it many years ago, now somewhat dusty and bedraggled.

    After four years, Phnom Penh truly is the same same but different. I imagine too, how much I may have changed over this period of time. Since completing my higher surgical training, maybe I have become more confident in myself or maybe I am now more acutely aware of the vast depths of surgical knowledge I am still missing. I have now published my most heartfelt words in a compendium of my surgical diaries for the world to read and sometimes I feel more assured of myself, at peace with all the encouragement I have received but sometimes I fear my writings have made me more vulnerable, more afraid of what others may think of all I outwardly express. Perhaps too, over the last four years of my life, there is now a brand new shining facade that is papering over my old cracking skin and creaking joints. I wonder how much I have changed physically and in spirit over the last four years or if I have become dusty and bedraggled like my soft toy, forlornly displayed in the clinic. Perhaps like Phnom Penh and our impoverished patients, I too am the same same but different.

    With love always,
    Saqib

    My old soft toy, still hanging in the clinic – needs a clean!

    The streets of Phnom Penh:

  • The Final Frontier of Surgery

    Dearest Readers,

    Medical and surgical research is breaking boundaries at an astounding pace. From genetic modification and stem cell therapy to robotic and 3D printing technology, scientific advancement is finding novel, unique and unprecedented solutions to complex, challenging diseases. Indeed, such is the rate of change that I am certain the last eight years of my surgical training in the UK will likely be rendered obsolete within the next twenty years of amazing, exciting, ground breaking advancements. Read More

  • The Universal Drug of Hope

    Note: Permission to use photograph obtained

    In February 2010, I completed my final ward round and said goodbye to my patients in Haiti just six weeks after a tragic earthquake. This earthquake was a natural disaster so devastating that within a momentary blink, a minute’s tremor and a rumbling collapse, an estimated one-hundred-thousand people lost their lives.

    Amidst the wreckage, hundreds of thousands more were left severely injured, shocked, traumatized and homeless. Haiti, an already impoverished nation, a victim of centuries-long political instability and the frequent rages of vicious typhoons, was now paralyzed from the head down.Read More

  • My Clever Night-Night Shoes – A Book Review

    Clubfoot is one of the most common orthopaedic congenital defects, affecting approximately one in a thousand births and there are an estimated 150,000 babies born per year with the condition in the world. Although there is a genetic component, the exact cause remains unknown and the condition is prevalent in every population group worldwide.

    In the distant past, club foot was often treated (and rather unsuccessfully) with extensive surgical procedures. However, more recently, a management algorithm using a simple plastering technique (the Ponsetti technique) has proven to give excellent long term results for the vast majority of children. Indeed, the technique is so effective that there is now a global campaign to improve the lives of many children throughout the world (globalclubfoot.com/) and prevent heart breaking neglected cases as seen below.Read More

  • The Science of Hope

    Dear readers,

    As I travelled to sporadic, distant destinations in the world, with my clumsy feet and widened eyes, to locations of severe austerity, I palpated a surprising theme of universal hope in places I did not think it was possible to have.

    From the spinal victims of the Haiti earthquake – left paralyzed in the collapsing rubble, to the teenagers with advanced bone tumours in Cambodia – still believing in cure, to the young and enthusiastic surgeons of Ethiopia – determined for a better future for their patients, a weaving pattern emerged of hope in uncertain times, a centrally bound thread that seemed to bind us altogether. Indeed, so powerful was this connection that I once described hope as the most valuable currency in the world, for it kept us alive and richer than money itself, and could be traded for beautiful, priceless memories as we got older.Read More

  • One act of hatred, a thousand acts of love

    Dearest readers,

    There are times when the world cannot be understood, when it is so overwhelmingly sad, so inexplicably cruel. The events in Manchester are so sickening and indeed, so overbearing that it is far easier for me to hide away from the images of the media, to turn off the news, to put away my phone. Merely contemplating the sudden loss of happy, innocent lives at a once-joyous event and the everlasting grief caused by the madness of this truly evil act is difficult for me to comprehend.Read More

  • Goodreads Giveaway

    I am giving away three signed copies of my book, Surgery on the Shoulders of Giants via a Goodreads Giveaway. The deadline for entry is June 12th 2017. I give away the books because I want to write letters to the winners, thanking them for their entry, adding to the collection of deeply personal letters already embedded within the book, describing all my travels abroad.

    Click here to enter

  • Book release: Surgery On The Shoulders Of Giants

    Surgery on the Shoulders of Giants is a heart-wrenching but ultimately uplifting collection of letters written during the medical travels of Saqib Noor, a surgeon in training and a doctor passionate about healthcare in impoverished areas of the world.

    Saqib qualified from Nottingham Medical School in 2004 and subsequently has embarked on a career in orthopaedic surgery. The events in the book are described in real time, beginning in South Africa with a series of personal and vivid letters, and continues over a ten year span in various countries and settings.

    The writings describe the disasters of the Haiti earthquake and the unprecedented Pakistan floods of 2010 as well as travels to South Africa, Cambodia, Ethiopia and Myanmar.

    The letters reveal the immense complexities and challenges of medical work in austere environments as well as the emotional toll it takes on all involved. The stories are filled with sadness yet inspired by hope and truly promote an underlying faith in the goodness of the human condition.

    The book is recommended for anyone wanting a terrifically unique human insight into medical care during disasters and the health challenges facing some of the poorest parts of the world.

    These letters are likely to stay with the reader many years after they have been read.