Leaded up and discussing the ERCP. Nurses here all wear these classic-style uniforms.

I kicked off the day with an exciting opportunity – today was a scheduled list of endoscopic retrograde cholangiopancreatography (ERCP), a top Scrabble word well worth memorising. It’s also a highly specialisedway to examine diseases of the pancreas and bile duct using real-time x-rays, fluorescing contrast injections, and a long controllable tubal scope passed from the mouth through down to the stomach and duodenum. This hospital is renowned for its surgical work in these areas, so it was a good chance to see the masters at work.

ERCP has become less common as radiation-free options like ultrasound have become more powerful and readily available for some of the roles it fills. It’s not replaceable for many of its therapeutic indications, however, so it was great exposure to get to see it in action for the first time. It was admittedly hard to follow some of the probe work as I peered over shoulders in my full lead suit, but I understood better after seeing a few more cases and asking a few more questions. Some of the patients looked truly cachexic, and I could see their muscles wasted from their progressed cancers. I wanted to be able to reassure them in some way, but even without the language barrierI don’t know what I would have said.

Tidying up an extensive venous ulcer.

Back in the surgical ward, I joined in on a wound dressing tutorial hosted by a senior nurse. There wasn’t a lot of new learning to this, but I did marvel at his impeccable technique that belied his years of experience. The crowd of medical student shifts from point to point around the hospital ward, and there always seems to be some form of tutorial that’s being hosted for them. I shadowed them into what I thought was another tutorial, only for me to eventually realise that they were discussing the hospital payroll mechanisms in Sinhala to the junior doctors. Maybe they thought I was planning on hiding under the floorboards until they had to pay me.

Next on my agenda was to try to find those quality teaching clinics. I found the room, and there met the Australian students who were busy trying to get signed off for their required assessments. We discussed the cases they’d seen, and the cases they were keen for when they got grilled. I’m working on my bread and butter presentations, and spent last night going through hernias of all shapes and locations, hoping for one today.

The surgeons entered the clinic, and we shadowed them to the bedside along with a few other local students. They’re all pretty on edge, as tomorrow’s their big exam. The school seems quite happy to keep people back if they don’t jump the bar, so it’s a lot of weight on them. Crowding around the bed, we saw a man with his groin partly exposed and a bulge in his lower abdomen. The thing with medicine, is that no matter how long you rehearsed to perfectly identify something, it’s never a good thing to be right about it. And so, despite battling my conflicting emotions about my three hours of study the night before, I resisted the urge to exclaim “Yes! You have a hernia!” My newfound passion for hernias aside, it was too early to drill down on where specifically it was, or even conclude a diagnosis without a good examination that ruled out other pathology (like a testicular or blood vessel origin, or an abscess or fatty lump). One of the local students stepped forward and danced through a beautiful, thorough examination while the surgeon looked on. He tolerated this for a while, before the critique began. She had done a good job, but missed a few manoeuvres, and were she to do so in her exam she would not be passing. I shot a look the others, who clearly shared my thoughts – it was a better exam than most of us would have managed.

Named for the East Africans enslaved under Portugal. They still form a minority.

It was almost the end of the day, and we were invited to catch up with some of the surgeons after work for dinner on the disturbingly-named Slave Island (which, it turns out, really has a basis in the Portuguese slave trade). Before that, though, I still had my washing to sort. My bags were too small to carry it all, so I brought it partly in my arms and partly in my hands to the only place I could find that washes clothes and doesn’t invoke terror upon reading their Google Reviews. The outfit was thirty minutes away bytuktuk, and handily right next to the Italian Embassy, so I got to walk past a dozen or so armed guards while trying not to look too crazy with my head poking around the corner of the dirty laundry pile stacked almost over my head.

Job done, I got back on the bus to meet the surgeons. The live music at the restaurant was fantastic, but not as fantastic as when I got quizzed on a radiograph that someone pulled out on their phone, humorously asking if I knew what it was. It was situs inversus in Kartagener disease, a case I’d seen previously in New Zealand and never expected to see again. A ridiculous slam-dunk, on something I had no business knowing when my foundations are still rocky, but I’m going to say I’m now firmly in the green for a credibility cushion of five to six dumb questions and maybe even a bad hernia examination to boot.