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Rural surgery

Ms. X was a young lady who presented to us with altered sensorium after a fall.  She was arousable but not responding  relevantly and there was a difference between the size of her pupils. A ct showed a huge extradural hematoma pushing the midline across to the other side. This is a life threatening condition and needs immediate surgical attention. 

Today in any city she would be referred to a neurosurgical centre. The centres in most cities are in large tertiary hospitals, mostly corporate in nature. Government facilities that handle cases of this nature are in capital cities. Most district hospitals will refer to state capitals. This will invariably mean further travel, time , and money, all scarce resources that further jeopardise the chances of survival. 

What does a doctor in a rural hospital confronted with this situation do? 

The breadth of the art and science of basic surgical training has departed from the curriculum of the general surgeon today, abdicated to the genre of specialist surgeons. Not that the specialist surgeons do not have elective rights over such surgeries, but I enter my plea that general surgeons also need to be equipped with skills and science to handle such situations on emergent grounds. 

We were able to evacuate this hematoma. There was a sagittal sinus bleed which was controlled with difficulty. The lady left us with no residual deficit. While I write this, I testify to what I call the “G factor”, which operates in situations where we have no one else to turn to. In my fifteen years of work in this place, I testify to the healing that comes from God. This operant factor may get displaced into the wings by “advancement” and technology, but in their  absence occupies centrestage. 

What does rural India need to handle such emergencies? Referral is an abdication and a wilful death sentence inscribed with every stroke. I am not a neurosurgeon, but I was trained at Christian Medical College Ludhiana to handle such emergencies. Are our young surgeons of today being similarly equipped or denied the skill under the guise of a sacrosanct speciality? 

What do we do as faculty to equip our surgeons for the rural patients of tomorrow? 

 

Let it snow!

Manali received a foot of snow overnight two nights ago, and there is prediction of more to come. So keep warm everyone, the snow is finally here! 

Surgical camp in Pangi

SURGICAL CAMP IN PANGI 2018

Killad in Pangi, Chamba district is one of the most remote regions in Himachal. Hidden behind formidable mountain ranges, accessible only by one hazardous road carved into rock face four hundred feet above a precipitous gorge cut by the  Chandrabagha river, it is a full day journey from Manali. Our team was to leave for Pangi on the morning of the 15thSeptember. The entire team of doctors slowly assembled on 14thSeptember. Dr. Joel, anesthetist from Baptist hospital Bangalore, Dr. Hansdak, eye surgeon from Pondicherry, Dr. Anand Prajapati, radiologist from CMC Vellore, Dr. Annie Prasanti, Obstetrician from CMC Vellore, with her husband Dr. Anand, also an anesthetist. Dr. Annie brought along Joshua her 17 month son, and her father in law. The eye team members were old hands from CMC Ludhiana, Dr. Amrit, Santhokh Singh and Anil, participants of prior camps. Roads into Manali were a challenge, four laning work delaying arrivals as heavy equipment and machinery clawed and tore up the hillsides, carving the ambition of a highway through an already perilous path.

Consequently, our team this time was a large one. 29 people all told, were packed into two travelers, one bolero and a pick up groaning with all our equipment. Anesthesia machine, operating microscope, slit lamp, generator, lights, cautery, suction machines and all medicines that we needed to conduct safe surgery in a wilderness had to be transported. This journey normally takes two days but this time we pushed through in one, a tribute to the border roads organization. We settled into accommodations and had all of Sunday to set up our workspace in the civil hospital Killad.

The old hospital, our earlier venue,  is an ancient dungeon like wood and stone structure that has succumbed to the ravages of time. This year we were presented with a spanking new hospital with tiled floors, large spacious well lit wards and new furniture which was a rare treat. The operation theatre area however, was uncomfortably near the entrance, and had no provison for scrubbing or cleaning and preparation of instruments! Finding a space for eye surgery was a challenge. It is a travesty to realise that so much public money would go into a spanking new building, only to omit essential functional aspects that compromise patient care. The labor room, for example was an oversight, and has been entirely omitted from the building!

Our camp started with a prayer on the morning of the 17th. Huge numbers of patients had to be herded into lines that snaked through the doctors rooms, laboratory and the ultrasound room, and then back to the doctors rooms. The ultrasound machine is always a fascination, people coming with a core belief that this box  held the answers to all their problems. Patients with headaches and joint pains remained convinced that a wave of the probe would fix their ailments, or yield clues to the causes of their disease. We saw over one thousand one hundred patients in five days, performed four hundred ultrasounds, and were able to get routine lab tests and xrays done.

This camp was refreshingly different from past experience. Earlier patients viewed us with suspicion and those who needed surgery subjected themselves to the procedures with a sense of impending doom. This time they had come well prepared for surgery, bringing with them bedding, old reports and were admitted most willingly, an index of the trust our team has now gained with the populace. Surgeries started up on the morning of the 18th. Over the next four days, we performed thirty major surgeries, nine minors, 21 eye surgeries, which averages to about ten surgeries a day. Most of these were done under spinal anesthesia but there was also need to administer general anesthesia. Our surgical teams functioned like smoothly oiled machines, safe, efficient and fast, making sure every patient received a high standard of safety and care. All of us felt and experienced the presence of Jesus, in the operating room. There were no complications or untoward incidents, and all the patients were cared for in the new wards by our super nurses.

The people of Pangi by nature are reticent and suspicious of good outcomes. Neglect, ill treatment, and death a frequent companion of disease, has caused them to expect the worst. Post operative days were primarily spent encouraging them to resume normal activities and convincing them to return home healed and well! Their smiles as they finally turned to go home were unforgettable as we reassured them that God had healed them!

Our camp finished on the 23rdSunday.  That was when all hell broke loose in Himachal. An intense high pressure zone camouflaged the entire lesser Himalayas and unleashed unceasing rain for the next three days. In Pangi, it snowed, much to the delight of the South Indians. We were ill prepared for snow as our thin shoes and jackets soaked. We lost electricity, connectivity and for the next three days, were unable to move out of our accommodations other than to make rounds and visit our patients in a similar predicament. All approach roads were cut off with landslides and landslips. Landslides are not an uncommon event in Himachal. Roads that are blocked are usually opened within a day or two by the Border Roads organization. Not this time. Reports of havoc happening in Manali were trickling in, as we heard of roads and bridges swept away by floods. By the third day we realized that we were not about to get out of Killad anytime soon. All roads were essentially impassable and we were trapped.

There followed intense negotiations by Dr. Bishan, our team leader, for helicopter evacuation. In improbable situations, we saw the hand of God organize our evacuation. The Assistant commissioner for all the roads in Himachal happened to be staying in the same guest house we were occupying. He promised safe passage for our visiting doctors via Kishtawar. Fortuitously we found a force traveler, and they left Killad on the 27th. They were to still experience more adventure as that road also closed in on them requiring them to walk across the landslide to resume their journey. The rest of our team however was still sitting pretty in Killad.

We spent the next two days vainly looking up at the sky for the promised helicopters. Finally, our saviours from the sky did descend in the form of two IAF helicopters which ferried our seventeen members out  to Chamba over two days. From Chamba we made our way back to Manali via back ways, since the highway to Manali was washed out.  Our drivers brought the vehicles out via Kishtawar. Eventually by Sunday, all our team members were safely at their homes.

This was a camp to remember for all of us, a tremendous testimony to the lordship of our God, working out every detail for us in the midst of a natural disaster. Everything got done. Everyone returned safe. Every life was impacted, both the served, and those serving.  We are forever grateful.

 

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The LWH team. 

LAMINAR FLOW IN OUR OPERATING THEATRE

The story of our hospital has been a study in God’s provision for our needs. Dr. Dennis is our orthopedic surgeon, who has joined and is capable of doing advanced orthopedic surgery. Prior to his joining our patients needed to go to Chandigarh for this. Orthopedic surgeons have to punctilious and obsessive compulsive about preventing infection in the bones, and an advanced operating theatre is required for joint replacement work. The air entering the operating theatre has to be filtered through HEPA (high efficiency particulate arresting) filters, and blown down onto the operating field and then sucked through vents in the corners so no air recirculates or returns to the operating field. Modifying an operating theatre to meet these standards is a large expense.

We are very grateful to the family of Ms. Mangala Billson (who decided to donate a portion of her legacy to us). Mangala Billson was born in England in November of 1948, moved with her family,in 1958, to new Zealand where she  later obtained a B.A.–majoring in psychology. Her 1st attempts at work were in journalism in South Africa on the staff of Readers Digest.  Mainly though, she spent many years of her life working as a counsellor, travelling to and living   in many places in the world though her base was always primarily in India.

In 2012 she found that she had colon cancer and died shortly before her 64th birthday. In her will she requested that a portion of her savings be used for those who need help–in India, a country she loved very dearly.  She had stayed for long periods at her brother and sister in law’s house above Old Manali and so was familiar with the people and society of this area.

We are also grateful to Interserve USA. With both these donors we were able to upgrade our operating room with standard pendant operating lights, and laminar flow. Interserve USA had a fund which was designated for use in India and was lying dormant for years. When we presented our need, they immediately sent across the required funds to us since it was designated for use in India but they had lacked an end user which fulfilled the requirements for disbursement. Dr. Chris Shin was the person instrumental in procuring this fund for us.

So these are both stories that fulfilled God’s timeline for this place, using donors whose hearts and intentions fitted onto the perfect timeline to ensure that the work here continues smoothly, providing solace and healing to patients of this region.

Is it not amazing?

Here below are the photos of the Late Ms. Mangala Billson, and also Dr. Chris Shin, and Drs. Rachel and Dr. Saroj in the new operating rooms. Dr. Dennis operating on the spine of a patient is also shown separately. 

 

 

 

 

Staff photograph

We are so grateful for each of our staff. We got together for our staff photograph this year. We reach out to each of you with our thanks and best wishes for the approaching Christmas season. 

 

 

Return from Kaaza 2017

Joule! The cheery greeting rang out as our cavalcade swept into Kaaza after an arduous twelve-hour bone-rattling journey over rocks that serve as a road. We were twenty-six people in three vehicles with one pickup truck jammed with all our equipment and supplies. We had left late from Manali because the “Raid Himalaya” road race was scheduled for the same day and delayed our departure. A rock falling on one of our vehicles provided some excitement as we extricated the vehicle, thankfully still roadworthy, and continued on our journey, to arrive in Kaaza by nightfall. Dr. Ganesan, a senior radiologist, and Dr. Pankaj Mallik, anesthetist, were the most senior in the group. Dr. Sathyavani, an obstetrician from Bangalore Baptist hospital, together with her surgeon husband Dr. Narayanswamy were the youngest consultants. Dr. Satish Thomas, a veteran of our camps, was the ophthalmologist from Believers hospital, ably assisted by Dr. Naveen from CMC Ludhiana, also no stranger to our camps. Mr. Rajinder, the eye technician from CMC Ludhiana teamed up with Mr. Shivdayal, our eye technician. The entire team of surgeons, nursing staff, operating room staff, anesthetic technician, lab technician, pharmacist, drivers, helpers, and a cook was quite a posse, headed by our dynamic leader Dr. Bishan Shasni, who actually works out the logistics of all our camps every year. Without him, I do not know if we could successfully complete any camp.

This year was different. In previous years, the camps had always been funded under the NRHM or the national rural health mission. This year, the government was late in opening the expression of interest. This invitation provides a pathway for organizations to apply for funding for the conduct of these surgical camps and expenses are reimbursed at government rates. The only certainty was that winter was fast approaching together with the reality of the high mountain passes closing for the year, cutting off these people from access to health care and surgery for the year. Every year we have been providing elective surgical services to the population of twelve thousand people living at this high altitude. For many who could not afford to leave the valley, we were the only recourse, and this year we did not have funds for it. So we prayed, and we felt that we should go ahead with whatever money we had with us to continue this service. So this year, this camp was conducted with our own money. The costs of arranging such a camp are not small, given that all expenses have to be met, and the patients are treated free.

Since it was too late to set up the operating room, the vehicles were unloaded and the team retired tired. The next day the morning was spent in setting up the operating theatre. The outpatient clinics started after a brief meeting with the public explaining why we were doing this and sharing our motivating factors with them. Dr. Bishan shared our commitment with them and explained our endeavor over the past years. The outpatient clinic was packed, with long lines of patients waiting to be seen by the general surgeons, gynecologist, and the eye doctors. The ultrasound machine was most in demand. Patients arrived, wanting an ultrasound for their headaches and backaches. The perception was that this little box would uncover any hidden disease by one wave of the magic probe. We had trouble with the ultrasound machine, but the ever-resourceful Dr. Bishan managed to solve the issue. Dr. Sathyavani was impressed with the antenatal care received by the ladies with the existing facilities, though for most of the pregnant women, the single ultrasound examination we conducted for them would be the only one done. 

That very day we were required to perform an emergency surgery on a patient in acute distress. Dr. Narayanswamy handled the situation immediately and the patient was relieved of his pain. One wonders what the patient would have done if we had not been there. He would not have been able to make it nine hours to the next surgical facility (ours) in Manali. One consequently wonders how people manage all year round. Though the kaaza civil hospital where we had set up base had enough facility for safe surgery under local or regional anesthesia, there is no surgery being done here until we arrive every year.

Over the next four days, we saw one thousand two hundred patients, performed 23 major surgeries and 24 minor surgeries, 25 eye surgeries (mainly cataract surgery), and conducted over four hundred and sixty ultrasound examinations. Every department worked smoothly, the members functioning together ceaselessly to provide a high standard of surgical and medical care. This being the fourth year of our camps, we testify to the faithfulness of God in providing care and healing to every one operated upon without a single complication.

Because Dr. Swamy and the surgical resident Dr. Shreya were able to finish all the minor surgeries in the morning, our operating lists finished every day by dinnertime, which was different from previous years, when the lists used to finish at two am, since we started late. Surgery for gallstones was by far the most common surgery. There was a patient in sepsis with a burst appendix and a little boy with abdominal tuberculosis. For both these patients, our intervention meant life saved. Most surgeries were conducted under spinal anesthesia. We had brought in every piece of equipment and medicine, down to the sticking plaster and bandages.

It was cold in Kaaza. We were at the very cusp of winter, and to emphasize this, there was fresh snowfall one night that dropped the temperature and sprinkled snow on the high pass. For some in our team, this was a new experience. The final days had some highlights in being able to visit the highest post office in the world (Komik village), where every team member posted a postcard to their homes. We were also very grateful for local co-operation and hospitality as we were hosted for a meal on two occasions. Our cook and helper had kept us very well fed and though a few of us had headaches due to the altitude, none of us fell ill.

It was with a sense of accomplishment and gratitude that the entire team departed from Kaaza on the 16th morning, satisfied that we were able to do this yet again, this year. We bid a fond “joule” to the wide open spaces and stark scenery, the cheery smiles of the amazing people living in this region, imprinted not just in our cameras, but in our hearts. 

 

 

 

Surgical camp to Kaaza

The team is assembling, the staff is busy packing all that is needed for full-scale surgery. We hope to leave on Sunday with our posse for Kaaza. This year the government has not opened the expression of interest as yet. That is very tardy and late in the year for the people of this region, because in a few weeks, the pass will close, isolating them. What that means is that we are doing this on our own now, not funded by the NRHM at all. We decided we could not leave the people without help and we will find other sources of funding or use our own to fulfill this mission. 

So our team hopes to depart Sunday morning, the 8th of October and return on 16th of October. 

Kaaza, here we come!

Tribute to a doctor

Even now as the ENT camp is in full swing in Manali, with hordes of patients waiting to be seen and operated in Lady Willingdon Hospital Manali, we pay tribute to Dr. George Ani, the surgeon who pioneered this and made it possible. 

Dr. George finished his MBBS from Christian Medical College Ludhiana, and then specialised in ENT from Christian Medical College Vellore. He stayed on at Vellore to be come faculty and specialised in voice and hearing disorders. 

His heart always went out to those who did not have. In an attempt to make a difference, he spent his own leave travelling to far flung and remote areas of India to provide ENT services, operate on people and help needy locations. 

He started providing this service in Manali biannually since 2009. Every year, he used to come twice and see about 500 patients and operate through the night to give those who were deaf, the miracle of hearing again. For the people in this region, this is nothing short of a miracle, since the only other option for them is to travel to Chandigarh for similar facilities, at an exorbitant and often unaffordable cost. He also used to bring surgeons from other parts of India to help him here. 

In late February 2016, while cycling from Vellore to Bangalore, he was hit by a speeding vehicle and died in a tragic accident. He leaves a huge lacuna, not only in his family and his institution, but in all our hearts,  here and in various hospitals scattered all over India, who remember the kindly doctor and his ministrations. 

Here he is seen with his wife, Dr. Annie. 

We know you are with Jesus, George but  we miss you!