What would you do if someone told you that you had to perform an emergency abdominal surgery on a stranger—even though you were not a doctor—and if you refused, the sick person would surely die?

In my fourth year of medical school, the students had the option of doing an elective semester anywhere they wanted. I chose to do a surgical rotation at a charity hospital located in a picturesque area about 150 miles north of Delhi, high in the foothills of the Himalayan Mountains between two great rivers, the Ganges and the Yamuna. I hoped to spend two months at the charity hospital and then trek around Annapurna in Nepal with John, a young American doctor who hired me to travel with him in the mountains for a month and show him “the ropes.” In return for my services as a “guide,” John paid for my round trip ticket to India and covered all my travel costs while in India and Nepal.

The application from the charity hospital arrived in the mail. Exotic stamps covered the airmail envelope. Some of the questions on the thin paper took me by surprise. One question asked about my religion. Another asked if I took Jesus Christ as my savior. After considerable reflection and inner dialogue, I answered that I was Christian and that I took Jesus Christ as my savior. Clearly I had applied to an evangelical Christian charity hospital.

Three weeks later I got the acceptance letter in the mail, written by the chief surgeon, Dr. Malik (not his real name), welcoming me to join their staff. He asked in the letter if I could bring some medical supplies with me to donate to his hospital, informing me that the hospital relied almost exclusively on shipments of donated hospital supplies and equipment sent periodically by a group of churches in the United States.

I departed on my adventure abroad in January of 1983. I spent a few days in Delhi exploring the city and buying appropriate clothing to wear at the charity hospital, like the salwar kameez, an outfit with loose pants, a knee-length tunic, and a long silk scarf.

From Delhi, I took the train to the high country where the little one-story hospital stood in the center of a large compound full of fragrant English flower gardens and several old houses from a bygone era. The compound had been owned by a wealthy Indian family for generations and then donated for use as a hospital dedicated to the poor.

During my orientation, I discovered that Dr. Malik, the so-called chief surgeon, was the only full-time medical doctor for the entire 30-bed hospital, a TB ward, and busy outpatient clinic. The rest of the medical staff consisted of volunteer nurses, medical students and residents, along with visiting specialists, like ophthalmologists and infectious disease experts, who volunteered their services for a few weeks at a time. The volunteers mostly came from English-speaking countries like the US, Canada, the UK and Australia.

One of the volunteer staff members, a tall Sikh called Rupinder, had been sent by his surgical residency program in Delhi to do a six-month rotation at the charity hospital. Not being Christian, he kept to himself—but that changed shortly after I arrived. For the last two weeks of his service at the hospital, Rupinder and I socialized together with long conversations into the night about customs and culture in India.

Two Indian nurses in starched uniforms tended the patients lying in the narrow metal cots. A third nurse named Ginny worked as a volunteer. Her church in the Midwest encouraged her to go out into the world and serve the poor as a way of healing from her grief after the death of her brother who fell into a mineshaft while hiking in the desert in Arizona. Ginny and I shared a room in the dormitory until she returned home three weeks after I arrived.

As we walked around the small hospital, Ginny told me that the patients supplied their own bedding. They got much of their care from their family members who camped on the floor next to their beds for the duration of the recovery. They supplied their sick family members with food and changed their dressings. The patients without family did not fare well and often went without regular meals and only periodically had their dressings changed. Ginny said the wounds rarely got infected even though the dressings looked filthy to me.

I met two medical students from Australia who were finishing up their electives and getting ready to return home. They told me quite a few fascinating stories about their experiences. I learned that the scarcity of antibiotics is so great that the patients who are treated with penicillin have to collect every drop of their urine in a container so that the penicillin can be distilled out of the urine and used over and over for other patients with infections. (I actually remembered learning in biochemistry class that penicillin is eliminated almost completely unchanged in the urine.)

The young medical students assured me that I would have a “mind blowing” experience during my stay. They wished me luck and in parting, one of them said suggestively, “You will see and do things here you never could have imagined in your wildest dreams.”

The next morning, after a breakfast of hot tea and pan-fried dough stuffed with curried mashed potatoes, eaten with the right hand—the left hand is used for bathroom activities and is supposed to remain in one’s lap—the staff headed off to the clinic where a long line of patients waited in silence. None of the patients spoke English. Some of them had walked several days to reach the clinic, not having money for transportation.

My very first patient sat slumped in her chair next to her husband. The interpreter was not available at that moment. In preparation for my trip to India, I had learned a few phrases for taking a medical history and some phrases to make polite conversation. Through mime and a few questions in rudimentary Hindi, I gathered that the man had carried his wife on his back for an entire day while walking down the mountain to the clinic. His wife was too weak from the abdominal pain to walk the long distance to the hospital on her own. I asked the sick woman to show me where her pain was. She stood up and pointed to the area just below the breastbone, the usual place of pain caused by gastritis, esophagitis, or gastric ulcers.

When the wife sat down, the husband said the word “x-ray” repeatedly and emphatically. Not knowing what he meant—even though he said the word in English—I grabbed one of the nurses and asked why the husband kept saying the word “x-ray.”

The nurse said that the patients who come to the clinic think that x-rays have magical healing powers. They think that the radiation and mysterious pictures can cure most of their problems. The nurse apparently knew about the placebo effect and suggested I go ahead and order an abdominal x-ray so the couple would feel better.

The x-ray showed no abnormalities, as predicted. Just to hedge my bets in case the placebo was not effective, I also gave the couple a bottle of Mylanta, an anti acid remedy I found in one of the boxes of medicines donated by an American church. Through mime and a few words in Hindi, I demonstrated how the bottle should be shaken back and forth and then given a few little blows to the bottom of the bottle each time before giving his wife the capful of medicine when she felt the upper abdominal pain. The couple left with a smile on their faces and thanked me.

One week later the husband returned to the clinic alone. He spoke in a loud and angry voice. I asked one of the nurses to come into the room and help me translate. The husband said his wife had gotten much worse from the American doctor’s treatment. He told the nurse he had done exactly what I had said: He had picked up his wife and shaken her hard and also hit her bottom several times before giving the capful of Mylanta. I could see the nurse barely suppressing a smile.

Mortified by the miscommunication, from that day forward I studied Hindi each night before bed. Rupinder let me practice my new phrases with him. He found my attempts amusing.

Not long after I arrived at the hospital, a visiting ophthalmologist held a weeklong clinic for people with eye diseases. Word had spread to the surrounding villages and into the mountainous areas about the visiting ophthalmologist. By sunrise on the first day of eye clinic, about 40 people had already formed a line in the courtyard, waiting to be seen. Since the ophthalmologist was short-handed, he asked if I would assist him with the surgical eye procedures. What a thrill. I spent the entire week assisting with the delicate cataract surgeries performed while looking through a magnifying glass.

The Australian medical students were not kidding when they said I would see and do things I could not ever have imagined. One evening as I prepared for bed, someone banged on the door of the women’s dormitory. Rupinder called out in a loud voice, “Doctor Erica, get dressed and come quickly. I need your help.” I ran out the door and into the courtyard where Rupinder waited for me. We ran to the entrance of the hospital where a large mound of charcoal in the shape of a human lay sprawled out on the ground. Moaning sounds came from the charred heap. “Rupinder, what is happening?” I asked with a sense of sickening dread.

He answered, “It’s another case of wife burning. Unfortunately, it is not uncommon in India, especially in rural areas.” He said he saw a truck drive up to the hospital. The driver got out of the truck and pushed the charred body out onto the ground, then sped away. Rupinder called the police but knew that they might not show up. He said wife burning was not a high priority for the police.

Rupinder explained that wife burning is a crime, but often goes unpunished. The men who douse their wives in kerosene and set them on fire do it because they want more dowry or goods from the bride’s family—or they simply want a new wife. They choose to kill their wives by burning them to death because they can claim that the death was just an accident that happened while cooking. After the bride dies, the husband is free to remarry and get another dowry from the new bride.

The police never came. The charred woman moaned continuously. Rupinder said, “We cannot save this poor woman. We must take her out of her misery.” He asked me to help carry her body to a little room on the side of the hospital. The woman gave out weak high-pitched screams from the pain of being moved. Her body was so badly charred that it was impossible to tell if she was a man or a woman.

Rupinder went to the dispensary and got a syringe full of morphine. No veins were visible through the charred skin. He injected into what he hoped was the inguinal vein. Within a few minutes the woman began the labored breathing that precedes death, accompanied by strange, otherworldly high-pitched sounds. Then she was silent. Rupinder checked to make sure she was dead. I stood in disbelief.

Rupinder urged me to go back to bed. Sleep never came to me that night as I tried to digest the horror that I had just witnessed. I have never forgotten that woman.

The next day I resumed my normal routine at the clinic. In contrast to the misogyny that I witnessed the night before, my first patient of the day, a mountain woman with abdominal pain from parasites, came accompanied by all four of her doting husbands. The four husbands were brothers. They treated their sick wife with a tenderness that I had not seen before among couples at the clinic. The brothers married the same woman because there was a shortage of eligible women in the remote village where they lived high in the mountains where polyandry was still practiced.

Just before my rotation ended, I saw another sad case of misogyny. Parents brought their little girl to the hospital because her body began stiffening several days after getting a cut while playing in the dirt. No one cleaned her wound. By the time the family reached the hospital, the young girl had such severe tetany, she could barely open her mouth to drink water. The parents left their daughter to die a miserable death alone at the hospital. Through a translator, I learned that the father said, “One less girl to feed and no more worries about the dowry.” I sat with the little girl. I sang songs to her and held her stiff body in my arms, rocking her gently. She died the following day. The staff made a little coffin for her and buried her on the premises.

A young evangelical Christian couple from Kerala in southern India, both internists volunteering their time, let me know that they had started a Bible study group that met one evening a week in the conference room. They asked me to lead the next week’s Bible class. They wanted me to talk about a specific chapter in the Bible. My mouth went dry. I had not read the Bible since childhood. I asked Ginny to lend me her Bible and looked up the assigned chapter and read it word for word.

How could I give a talk about a chapter in the Bible when I knew so little about religious matters? I stood in front of the room with my heart racing without anything to say. I made a silent plea for help, then took a deep breath, let it out slowly, and said in a calm voice, “For today’s Bible class I’d like us to discuss this chapter together—instead of me just talking about my own thoughts. I’d like each of you to share with all of us your thoughts and questions about this chapter. Ginny, would you like to start? ” The two hours of lively, impassioned discussion passed quickly—without much input from me, other than guiding the flow of the conversation. The internists expressed their gratitude for the meaningful discussion.

One morning near the end of my rotation at the hospital, as I was walking back to the dormitory after breakfast, Dr. Malik asked if he could speak to me. From the tone of his voice, I sensed he had something urgent to tell me.

In his heavy Indian accent he said, “Doctor-ji, I want to tell you I am very pleased with your work.”

I wondered why he addressed me as “doctor” since he knew I was a mere medical student. And why did he use the suffix “ji,” an honorific term of respect. I sensed something serious was about to happen.

“I must go on a trip to Delhi for an important meeting about funding for our hospital. We have an emergency we have to deal with immediately. A man arrived this morning with acute appendicitis. We are short on staff at the moment. You will have to do the abdominal surgery.”

In utter disbelief, I said, “Dr. Malik, are you joking around with me?” I could see from his face he was dead serious. I said emphatically, “I am just a medical student. I am NOT a doctor yet. I have never done surgery in my life. In medical school I’ve only assisted with the suturing and holding the retractors for the surgeon. Nothing else.” Dr. Malik listened without any visible reaction. I said adamantly, “I cannot do this surgery. I will not do it. NO WAY. Besides, the patient would probably die if I tried to do surgery on him.”

Undeterred, Dr. Malik persisted. “If you don’t do the appendectomy, the patient will surely die from a ruptured appendix. You don’t need to worry, Doctor-ji. The anesthesia tech, Arpen, will tell you what to do. He has watched dozens of these surgeries. I most go now so I don’t miss the train. Good luck, Doctor-ji. Everything will be alright in the end.”

I staggered to a nearby bench as I felt the blood leaving my head and my knees buckle. My heart raced. Just as I began doing some deep, slow breathing to collect myself, Arpen, the anesthesia tech, appeared and said, “Doctor-ji, it is time for you to scrub up and prepare for the appendectomy.”

I walked robotically to the surgical suite wondering if the patient would survive. I tried to calm myself by saying that the patient would die anyway if I did nothing. I scrubbed my hands and forearms vigorously with the disinfecting soap; I dried them off with a terry-cloth towel—not a disposable one. An aide helped me put on the re-usable cloth surgical gown and the cloth covering for my hair. There were no more disposable face masks available for the surgery. Fortunately I didn’t have a cough or a cold.

The aide held a latex glove open for me. Maintaining the sterile technique I had learned in medical school, I dove my right hand into the open glove. My fingers went right through the latex and out the other side. The gloves disintegrated into little pieces of latex from being washed and reused many times. The aide said, “So sorry Doctor-ji. We have no more gloves. We are waiting for the next shipment from the church in America. You will have to do the surgery without gloves. So sorry.” I took a few seconds to digest the shocking news that I would be touching blood and guts with my bare hands.

I walked into the operating room and saw the naked, middle-aged patient on the operating table with only one re-usable cloth drape over his privates. A nurse stood nearby holding a fly swatter. The generator hummed in the background, producing the light we needed for the surgery. Arpen said, “I have given the patient the ether. He is unconscious now. We are ready to begin.”

I approached the operating table on the verge of falling to floor and passing out. At that crucial moment, I had a brainstorm that rescued me from fainting and filled me with confidence. I imagined that the body lying on the table was a sheep’s body.

After teaching school on the Navajo Reservation for two years, I retired to become a sheepherder for three months in a remote area of the reservation. I lived with a family that spoke no English, a great opportunity to perfect my Navajo. One of my jobs as a sheepherder included butchering the sheep. After I got over my initial revulsion—having been a former devout vegetarian—I became quite skilled at the procedure and performed it in a state of reverence, beginning with a Navajo prayer of thanks to the sheep.

As I stood at the table ready to perform major abdominal surgery, my focus became so intense, I forgot how terrified I was. I picked up the scalpel with newly-found confidence, ready to make the incision. I hesitated for a moment not knowing exactly where to cut. A three-inch bikini incision, as done in the States for cosmetic reasons, did not seem appropriate in this particular case. Arpen directed me to make an incision from the breastbone area to just above the pubic bone, similar to what I did when I butchered the sheep.

We had no cautery instruments, so I had to staunch the bleeding with the few pieces of gauze we had on hand, making the procedure very slow and bloody. I cut through layer after layer of abdominal tissue, just as I had done with the Navajo sheep. After about twenty minutes, I reached the intestines with the abdomen wide open. Now, how to find the appendix?

I knew the approximate location of the appendix from anatomy class. It was supposed to be in the right lower quadrant, just to the right of the belly button and a few inches down. I pulled out some of the intestines in that area, but couldn’t find the elusive appendix. I ended up pulling out several feet of intestines until most of the colon lay outside of the abdominal cavity, searching fruitlessly for the diseased appendix.

Eventually I saw something that looked like an appendix and grabbed the clamps. Just in the nick of time, Arpen intervened, “No Doctor-ji. Not that one. That is not the appendix. Tis that one over there. No. No. THAT ONE. Can you see where I am pointing?”

Finally, the true appendix appeared. It was inflamed and swollen, ready to rupture. I clamped off the diseased organ then cut it off with the scalpel. The nurse picked up the amputated appendix and threw it in the garbage.

Next came the suturing, the part I enjoyed and was good at, having sewed some of my own clothes as a child. After carefully suturing the area where the appendix had been removed, I faced the challenging job of stuffing all the intestines back into the confined space in the abdominal cavity. I imagined I was stuffing my sleeping bag into its tiny stuff sack, trying to break camp quickly before the rains came.

With the intestines tightly packed into the abdominal cavity, I pulled the layers of abdominal tissue together and sutured one layer at a time with thick, absorbable catgut sutures. A wave of relief washed over me as I sewed up the final layer—the skin.

“Good job, Doctor-ji. Why don’t you go get some rest. We will take the patient to the recovery room. You can round on him in the morning.” I scrubbed my hands and forearms and left the building.

Filled with both exhilaration and exhaustion, I was not able to accomplish much the rest of the day. Sleep did not come easily that night. I feared that the patient would bleed internally and die in the night.

When morning came, I decided not to wait for the formal rounds of the in-patients after breakfast. I went straight to the hospital, anxious to see if my patient was still alive. In my haste, I forgot my stethoscope.

As I walked into the hospital, I spotted my patient immediately because of the large dressing encircling his abdomen. Not only was the patient alive, he was sitting up in bed and smiling. I tried to say in broken Hindi how happy I was that he was alive. I gave up and simply leaned over and gave the patient an awkward hug. Then I remembered I needed to act like a real doctor.

I wanted to ask the patient if he had passed gas in order to determine if he could start drinking some fluids. I did not remember how to say those exact words in Hindi. Everyone on the medical staff was eating breakfast together, which meant that no one was available to translate. I improvised and asked in Hindi, “Is there wind in the south?” The man grinned and chuckled—so did the other patients listening intently to our humorous conversation. Tilting his head repeatedly from side to side, he answered my question, “Haan. Tikay Tikay.”

What a joyous time of celebration! Not only did the patient survive the surgery, I survived as well. Who would have guessed that my time with the Navajo Indians as a sheepherder would have helped me save an East Indian man’s life over a decade later?

I thought about my upcoming graduation from medical school in June when I would become a real certified medical doctor. Internship would begin in July, just three months away. After my experiences at the charity hospital in India, I felt confident I could handle the demands internship.

The day before I left the hospital to roam around in the Himalayan Mountains, the staff gave me a sweet farewell ceremony with Christian church songs I remembered from my childhood, sugary treats, little gifts and other expressions of gratitude.

The evangelical Christian couple from southern India made a leather bookmark for me with a verse from the Bible written on it in gold letters: Those who hope in the Lord will renew their strength. They will soar on wings like eagles; they will run and not grow weary; they will walk and not be faint. Isaiah 40:31

Amen.

Addendum: The appendectomy was the first and last abdominal surgery I ever performed.