The Scope of Practice

Never drink beer with the lights out. I’m not sure if your mother ever told you this, but it is good advice. This is because there is inherent danger found in this dark practice. The danger is, that it is just possible you may inadvertently swallow a bottle cap.

In the United States every medical student who completes medical school is given a certificate that states that they are permitted to practice both medicine and surgery. However, in reality, no doctor practices both of these things. They will either focus on one or the other, and it would be considered malpractice to do both. This is because which ever residency the doctor completes determines what their “scope of practice” will be.
For me, “scope of practice,” has become a sort of joke here in Nepal. I did my training in Internal Medicine, which focuses on medical treatment of adults for basic illnesses. However, since arriving in Nepal, I have had to assume the roles of Pediatrician, Obstetrician, Neurologist, Psychiatrist, Rheumatologist, Pulmonologist, Critical Care Specialist and Gastroenterologist. In Nepal there is no ‘scope’ of practice, but a ‘scope of what are you willing to, and think you can relatively safely do, because no one else is going to do it,’ practice.

A 24 year old man came to clinic after not following his mother’s advice not to drink in the dark.  He had been drinking beer with friends, and since the power was out (as regularly happens in our town) it was in the dark. Things were probably on the excessive side and bottle after bottle was being opened. There may have been loud singing too (as also regularly happens in our town) so it is likely that nobody noticed when, after a bottle was opened there was a ‘plop’ in a glass, rather than a ‘clink’ on the floor. This young man who was soon to be my patient slugged down the last draught of beer, and with it, swallowed the bottle cap.

He immediately went to the nearest hospital, where an X-ray confirmed, he had swallowed a bottle cap, which was now comfortably sitting in his stomach. An endoscopy was attempted (where a tube with a camera on the end is placed through the mouth, down the esophagus, and into the stomach) where the bottle cap was seen, but attempts to remove it been fruitless. He was referred to our hospital to have the cap surgically removed.
By this point the cap had been in his stomach for 3 days, and was not moving through on it’s own. It was too large to fit through the small pylorus, the sphincter at the bottom of the stomach. The surgeons evaluated him, and explained that he would have an incision in his abdominal wall, through the layers of fat muscle and fascia, down into the abdominal cavity and finally to the stomach where the cap would be taken out and everything sewn back up. It was not a minor surgery, and there was risk of complications both immediately and years down the road. That is, unless, the bottle cap could be removed by the local expert endoscopist. That would be me.

I have done around 200 endoscopies since arriving here in Nepal, which, although not a small number, does not make me an expert. This retrieval would be further complicated by the limitation of tools that we had to actually grab hold of a bottle cap. All we have is a biopsy wire, a thin line that could be passed through the gastroscope and out the end in the stomach. The working bit of this was a pair of opposing “grabbers” that were about 3mm long each which could be opened and closed by a lever on the end.

Upon starting the endoscopy, the cap was found in the stomach, although obscured by a fair amount of fluid, which could not be removed by the weak suction on our circa 1995 endoscope. Getting ahold of the cap proved to be quite difficult. After several attempts, we got a loose grip on the cap, but when the cap was pulled back to the esophagus, it spasmed and the cap slipped out of the tiny teeth of the biopsy wire. After 45 minutes of trying (and failing, despite getting ahold of the cap about 6 times) I called the surgeon to see if he had any other ideas or tools to get the cap out.
He sized up the situation and exclaimed, after looking at the size of the biopsy wire and the liquid in the stomach, “this is impossible!”
I replied, “it is worse than impossible, it is just barely possible!” There was the slimmest chance I could spare this boy an operation, but at this point it didn’t seem likely.
After another 15 minutes of trying, I decided this would be our last attempt. After a brief prayer, the most wonderful thing happened. The boy vomited. This cleared the stomach of all of the debris and liquid that was making it difficult to find the perfect angle to grab ahold of the cap. Now the cap was clearly visible, and we were able to find a firm grip on it.
Over the next 5 minutes we inched the cap back through the esophagus, pausing each time the esophagus spasmed as to not lose our purchase. As we snuck past the epiglottis and saw a tooth we all cheered, for we knew we had arrived in the mouth. He coughed the endoscope out, and the cap came with it.


If you had suggested to me 5 years ago the sort of things I would be doing today, I would have thought it crazy. There is no training program in the world that can prepare you to do the variety of things that have to be manage here. The things I am asked to do on a regular basis are far outside of my ‘scope of practice’, and our equipment is often not the right tools for the job, but with a little encouragement, the ‘do what has to be done’ attitude of the doctors here and the grace of God, people leave the doors of Tansen Hospital better than when they arrived, and sometimes with a little less baggage.