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Kaaza surgical camp.. reminiscence

Posted by: Philip Alex | Posted on: October 13th, 2014 | 0 Comments

 

 

SURGICAL CAMP IN KAAZA

 

The first fingers of the sun gilded the snow on the mountains guarding the Rohtang pass as our team assembled at dawn. An obstetrician from Baptist hospital Bangalore, eye doctor, optometrist and eye surgeon, anesthetist and radiologist from C.M.C. Ludhiana, and the rest of the team from the Lady Willingdon Hospital Manali gathered around the three vehicles. Only the pharmacist was missing, having been delayed arriving. The obstetrician declared his order of priorities in declaring the pharmacist dispensable provided the cook was on board. The cook was indeed on board, ready to feed the twenty mouths that climbed onto three vehicles bound for Kaaza for an NRHM surgical camp.

This camp was the result of years of anticipation and patient planning. It was the first time our hospital had directly organized such a camp, though members had been on such camps organized by other teams earlier. Our community consultant Dr. Bishan was the key person who orchestrated it. We gathered for prayer, and then the vehicles pulled out of the hospital courtyard.

The first leg of the journey involved crossing the Rohtang pass, at 13500 feet, to enter the Lahaul Spiti district north of the formidable lower Himalayan mountains. The towering mountains inspired gasps and repetitive clunks and clicks of the shutters of a variety of cameras, all desperately attempting to capture their magnificence in a digital format through a speeding car window.

A brief stop for a breakfast of paratas with a local chutney that brought tears of delight at Chattru, and the day seemed off to a very good start. The road (or what passes off as a road) was a challenge at every twist and turn, fording streams and rock strewn rivulets that objected to mankinds feeble attempts to tame wind and water. The mountain road soon gave way to what appeared to be a rock strewn desert, and every vehicle seemed to have liberty to choose a path of least resistance which they could then call a road. It was here that the Scorpio at the tail end of our little convoy suddenly stopped. The driver got out, and one look at his face was enough for the passengers to understand that all was not well. The support rod holding the engine onto the chassis had broken, and one side of the vehicle was listing badly. The other vehicles had since gone ahead so that left five travellers wondering what to do next. A passing taxi driver stopped by, sized up the situation and nonchalantly suggested that we jack the vehicle up, take the affected wheel off, and shore up the engine with one of the many stones littering the landscape. It seemed a preposterous plan, but we were game to try anything, and soon, we had an oval stone sitting snugly in the space between the engine and the chassis. The ministering angels’ advice worked, and he drove off in a cloud of dust, as we gingerly eased our vehicle forwards. We made it to Batal bridge, and were met by a return party setting out in search of us, wondering if we had fallen off the landscape somewhere.

A brief stop here for lunch, and then off again, to Kaaza. The road thenceforth is mile after mile of bone breaking jaw jiggling ride on rocks. We were grateful to arrive in Kaaza by evening. The entire team unloaded all the vehicles in the government hospital and set about the task of creating an operation theater. We had to reinstall the operating light and set up every piece of equipment. Our staff worked their magic on a very basic room, and transformed it into a professional operating room. This process begins with hosing down and wiping down the whole room, including the ceiling, installing every piece of equipment, then fumigating it overnight with a fumigation machine. While this process was under way, I noticed that the obstetrician was looking pale and cyanosed. Auscultation revealed that he was in pulmonary edema and his blood pressure had skyrocketed. So he became the first patient, as we rushed him into the ward, hooked him up on oxygen and shot him up full of Lasix and steroids. He needed monitoring through the night but was well enough by the next morning to come and see patients in the opd despite our requests to rest.

The Kaaza civil hospital is built on two levels, with the operating theatre on the ground floor. The wards are on the first floor and there is a ramp that allows patient transfer. The rooms on the ground floor were quickly converted into consultation rooms for the surgeon and anesthetist and gynaecologist, and the ultrasound machine set up next to the laboratory. An impromptu vision testing centre was set up in the corridor. Our medicines were stocked in the aditus next to the nurses station on the first floor. Everyone worked quickly and efficiently and all was soon ready to cater to the long lines of patients which were beginning to form already at eight am. There was a formal inauguration at nine am presided over by the local Sub divisional magistrate, and then the camp was in full swing. Out patient clinic went all day, and the very first day we saw two hundred and seventy patients. We had planned to see patients every morning and operate in the afternoons.

Though this was intended as a surgical camp, we were seeing patients of all ages, and with a variety of complaints, from the elderly lady complaining of gas ascending from her uterus to her head, to the little boy who sidled up and confessed to a large white snake emerging from out his behind. Surgical patients did arrive, but we found a great reluctance and a fear among the populace. We learned that complications from previously conducted camps had instilled a great fear in all the people. We had to work hard to overcome this.

Despite their trepidation, some patients did come forward for surgery, which was performed the next day. The first patient was a lady with an ectopic pregnancy. It was so fortunate for her that we were there, because just the week prior, a lady with a similar history was referred to a higher centre, but did not make it and died on the way, as did a patient with a ruptured appendix. Surgical options here are non existent, despite the presence of a utilizable operating theatre. In this day and age, patients having to die deprived of a surgeon seems a conundrum in the face of India entering the new millennium and bordering on the brink of being called a superpower. We can send a machine to mars to take some photographs, but our people still die with preventable surgical illness. Most surgeries, even cholecystectomies, were conducted under spinal anesthesia. The Boyles machine available does not have a closed circuit so long durations of anesthesia is fraught with the risk of hypercarbia. However, most surgeries can be completed within the hour, which is a safe duration for a spinal anesthetic. The operating surgeon therefore has to be skilled enough to complete the variety of procedures within the hour, and equally important is synchrony with his scrub staff and floor nurse. Speed is a double edged sword, and safety has to be the parameter paramount in the conduct of surgery. Perioperative antibiotics suffices for clean contaminated surgery, and no antibiotics are administered for clean surgery. Disposable drapes and gowns minimize the need to transport and autoclave sheets. As each surgery finishes, the staff clean and pack these instruments and ready them for the autoclave which is kept hissing and fizzing accompanying the music playing in the ot. Eight to ten surgeries can be thus safely finished in eight hours. Minor surgeries are interspersed with majors, as they require only a few basic instruments and local anesthesia. Two copies of the operating lists exist, one in the ot and another with the staff in the wards, and mobile phones are used to call up patients. Utilizing husbands or fathers name and village to prevent a wrong operation on the wrong patient protects each step along the path to surgery from error, particularly because every third person is called Tenzin. Every patient has an individual file which is meticulously filled with clinical details. Every patient is photographed pre and post operatively to fulfill the requirements of the NRHM and the case sheet is also photographed to for identification.

Congregation and banter around the dining table, which was always groaning with delicacies prepared by our camp cook, mark the end of the day. The cook was as important as a primary caregiver, since he constantly kept up the camp morale with ingenious dishes prepared with very basic amenities. For example, he made the pasta sauce, and a pizza base, and baked it inside a large aluminium dish converted into an oven by placing the pizza on four similar sized stones carefully arranged within. We never realized stones could have so many uses nor that camp pizza could be so tasty.

Over one thousand patients were seen in the camp, four hundred and seventy ultrasound examinations performed, fifty two surgeries safely conducted among which were twenty eye surgeries. Rounds were held twice a day and all the staff did a great job caring for the patients pre and postoperatively. All medicines were issued from stock carried with us who was able to thus keep a careful watch on their utilization and availability. Every patient received a discharge summary and a post operative follow up plan. We remained on site till the patients were safely discharged and none felt abandoned or without recourse to help. The local doctors were apprised of the plans for each patient and the patients connected with the doctors so that follow up would be smooth and uneventful.

It was with a sense of great satisfaction and fulfillment we then piled into the vehicles to return to the Manali base hospital. We were very grateful for every day, and for the healing for all the patients, many of whom would never have been able to have recourse to the procedures that we were able to do for them.

Well done Mission hospital!

 

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Whats the case?

Posted by: Philip Alex | Posted on: September 9th, 2014 | 0 Comments

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A thirty eight year old lady presented to our hospital with hemoptysis. She had no fever or chest pain. She has a history of hemoptysis one year ago, which subsided with no treatment. A close up of a chest x ray revealed the above pathology. What is the sign so well demonstrated, and what is the pathology?

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See the photographs

Posted by: Philip Alex | Posted on: July 30th, 2014 | 0 Comments

Some of the photographs from the Spiti camp have been uploaded to the Spiti gallery. Please see the latest snaps, because the snaps from the last year are also in this gallery. Happy viewing!

Report on the Lahaul Spiti camp

Posted by: Philip Alex | Posted on: July 21st, 2014 | 0 Comments

The camp in Lahaul spiti conducted by the LWH was a mega success. Two thousand and sixty three patients were seen in eight camps over the ten days. A detailed report is enclosed with significant observations which can form the basis for future work. We thank Dr. Bishan Shashani for organising the whole trip and the NRHM and the Tribal Welfare department for the funding to have made this possible.

Report modified

 

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Play ball

Posted by: Philip Alex | Posted on: June 3rd, 2014 | 0 Comments

 

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PASSING THE BALL

A team game is a pleasure to watch, as different players pass a ball along, to achieve a goal. Each player puts in his or her part, and the ball passes along, till it goes through a hoop or a goal with a resounding roar from the onlookers marking its passage.

Patient care is not very different, as the patient passes along in his or her passage through a health care facility, being passed along from department to department, each person contributing in varied ways to the healing that flows from the hospital. The patient recovers and leaves, but there is no resounding roar, only a calm satisfaction in hearts as we know we have done our bit in Gods great pattern of healing.

I stand in the operating theatre as the cases progress, and wonder and thank God for the team in Manali. For every one who puts their hand to the task of taking care of patients in whatever capacity, direct or indirect.

I am so grateful for every one, and for the team here, by which we work together like a smooth machine, taking care of people who come here, hurt, hurting and in pain.

We truly are a team. I am very thankful and proud of you. Let us continue to play ball.

http://surgicalspace.blogspot.in/2014/06/play-ball.html

Young boy with tb abdomen

Posted by: Philip Alex | Posted on: May 8th, 2014 | 0 Comments

A 11 year old boy was brought to us after having being run from pillar to post for the past year. He has been consistently unwell, with abdominal pain. We thought he had tb abdomen, and confirmed this with a diagnostic laparoscopy eight days ago, when we obtained a peritoneal biopsy. He was started on anti tb medicines while we waited for the report for confirmation.

He returned to us  yesterday with abdominal pain and distension and was admitted with intestinal obstruction. While in hospital he perforated. He was taken up for a laparotomy yesterday when four entero enteral fistulae were found (communications between the bowel which had happened a while ago). One of these had perforated. He underwent a resection and ileostomies. (The diseased part of the bowel was removed).

He is now on the ventilator, on inotropes (to support his blood pressure), and is fighting for his life. Please do pray. He still has a long way to go.

We are very grateful to God for Dr. Kaaren, visiting anesthetist who just happened to be here and helped get him off the operating table alive. Also for the many donors who have given us the equipment to handle emergencies of this critical nature… blood gas machine, ventilator, syringe pumps, etc.

We ask now for your prayers for him.

Shp (secondary hospital program)

Posted by: Philip Alex | Posted on: May 7th, 2014 | 0 Comments

The students from CMC Vellore are here on their secondary hospital program, accompanied by faculty Dr. Jacob John, consultant in community medicine. The batch is an all male team this time, and they have been accompanying doctors on rounds, in the ot, and to the peripheries to conduct clinics and check ups.

We thank CMC Vellore for sending them every year to Manali.

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Subdural hematoma evacuation

Posted by: Philip Alex | Posted on: December 18th, 2013 | 0 Comments

Mrs J is a sixty five year old lady who was brought to us with the history of altered sensorium and behavior for a day prior. She had already obtained a ct scan from outside which showed a large subdural hematoma (blood clot) in her brain compressing her brain to the other side. She needed a surgery. She was referred to IGMC Simla, but the family did not have the economic means to take her there. Manali was their last hope.

Having explained all the risks of performing this surgery in a relatively unsupported environment, we did a craniotomy and evacuation of the hematoma here. The lady made a dramatic recovery and is being discharged well. We thank God for the amazing recovery she made and for saving her life.

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Farewell again

Posted by: Philip Alex | Posted on: November 13th, 2013 | 0 Comments

We bid a fond farewell to Drs Anu Yarky, Dr. Shefali and to our Staff nurse Nisha Kumari with samosa and gulab jamuns  in front of the mess. All are going for further studies, and we wish them well. We had a bit of an emotional farewell. Emotions are always at the fringes of these functions, but this time, it overflowed!

 

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Lahaul Spiti camp

Posted by: Philip Alex | Posted on: September 29th, 2013 | 0 Comments

 

The access to this district is over the formidable Rohtang pass, and traversing the road into this region comes with its share of excitement. The land is a study in contrast from east to west. Cut off and remote, the people have learnt to survive in this harsh environment with an innate fortitude and strength. Every thing here is scarce. Water, electricity, health care, newspapers. Everything has to be brought in over the pass, and the outcome of every emergent situation is decided by whether the people can carry the patient out over the pass, or whether the patient is hardy enough to survive. Understandably, the average populace is hardy, and healthy, because only the healthy survive. Yet, they brave the inclement weather and circumstances with a cheerfulness and a smile that is humbling to the visitor. Medical care is provided by a chain of government health centres, which are usually staffed by a few doctors. Specialists and specialised care is scarce. Surgical services can usually be accessed only in Kullu, Manali or Simla. Recent reports of surgical care being a public health problem where people are unable to access surgery has been highlighted by reports from Sierra leone and Africa. http://www.who.int/bulletin/volumes/89/6/11-088229/en/. The situation in Lahaul Spiti is not very different and indeed, one can understand why surgery will elbow a place for itself as a public health issue. To meet this need, we will need to plan and execute camps in the future. The provision of safe surgery in remote locations is an incredible challenge.