• 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