Today was surgery day at Schell Eye Hospital. It started out with a little frustration that was quite hilarious in hindsight. Julie, Michael and I reported to the O.R. this morning, and were told to go change into the hospital scrubs. Julie and I walked into the womens dressing room and found piles of blue, paper thin, old, bleach-stained scrubs that were about four times too big compared to the scrubs we normally wear. The pants could have fit a family of five in the waist, and the top came down to my knees. They were literally so worn-out that I ripped them when I pulled the drawstring too tight. Julie and I threw them on over our clothes and started to walk to the O.R. hallway in our sandals to get footcovers. We were chastised (but very kindly) by a sister (I think I've mentioned that is what they call nurses here) who said we had to enter the O.R. hallway barefoot, then put the footcovers on our bare feet. We did so accordingly, giggling at the floppy cloth material that was also four times too big with a thin plastic sole. We thought we were ready, but oh no. The sister said we had to go back in and remove our street clothes, even though not one part of them was sticking out and we wouldn't be scrubbing in. We headed back to the dressing room, did as we were told, then re-emerged, only to be told we had to change our footcovers again. To make things even more interesting, I had forgotten to leave my valuables at home (camera, two phones, passport and wallet) and didn't want to leave them in the dressing room (a student last week had everything stolen from passport to new SLR camera at the hospital), so they were now tucked into my sports bra with my camera dangling from the drawstring in my pants. Lovely. I thought we were finally done, but then Jules had to go to the bathroom after all the delicious coffee we drank this morning so she had to do it all over again. After learning all the rules and idiosyncracies of the O.R. at home, I felt like a new third-year medical student again who doesn't know proper O.R. edicate. It was quite funny.
So, suited up in our surgery attire, we met Michael down the hall who was dressed similarly, but in white scrubs (all the men wear white, the women blue). We then met Charles (I'm pretty sure that was his name, though I haven't met an Indian man named Charles here yet), who was the head nurse of the O.R. He gave us a nice tour of the eye O.R. which included 4 operating rooms (or theaters, as they're called here), one which was reserved for paying patients, and one that was reserved for camp patients. (Brief explanation of camp patients: Back in the 60's and 70's, ophthalmologists traveled to the rural villages to do screenings and performed surgeries in makeshit operating rooms (schools, homes, etc.). Obviously the conditions weren't exactly sterile, endophthalmitis was a frequent occurence as well as other complications, and the government started mandating certain operating outcomes and parameters for the eye surgery "camps". Needless to say, that shut many of them down but established better rules, regulations and patient safety, and now great eye hospitals like Schell and others exist. Ophthalmologists still go out to the rural villages, but only to perform vision screens and bring these indigent patients in who need surgery but can't afford to pay. Hence the term "camp patient" was born.)
Our first surgical case was with Dr. Jeyanthan, a young, very kind comprehensive ophthalmologist from Vellore whose special interest was in neuro ophthalmology. However this morning he was doing a dacrocystorhinostomy on a woman who had chronic complicated dacrocystitis with cutaneous fistulae formation. I have seen several at home at Dean McGee and felt comfortable walking into the procedure, but was quite surprised when I saw the large amount of blood (large for ophthalmology, not large for general surgery...Carla) during the case and even more surprised by the lack of pain medication and sedation for the patient. She had some local anaesthesia, but it had pretty much worn off by the middle of the case when things got quite complicated and Dr. Jeyanthan couldn't thread the punctal tubes through the ostomy in the nasal mucosa. I was trying not to cringe as the patient cried and groaned in pain in Tamil, and was relieved when the case was over. I have a very high tolerance for blood and guts at this point, but hearing a patient in pain makes my stomach churn. The next patient was having a similar procedure, but he was a darling boy of four years. He was not happy to be in the O.R. without his mother and struggled as they administered general anaesthesia (little kids can't hold still enough like adults can for these procedures), and I tried to calm him by talking to him and stroking his arm before he conked out. The procedure went much better this time, and Dr. Jeyanthan was an excellent teacher who made sure that Julie and I understood every step of the way. He answered all of my questions, and I left the operating room quite satisfied that I could now describe every step of the procedure, something I hadn't been able to do before.
I was extremely curious about how the sterilization of drapes, gowns and instruments were done here, because absolutely everything was recycled and re-used. In the U.S., all of the drapes, gowns, towels, etc. are disposable and thrown away after each use with a new package opened for each patient, no matter if they have insurance or not, can pay for the surgery or not. Because resources are so precious here, they re-use everything! Charles explained the lengthy autoclave cycle for linens and the gas sterilization method using ethylene oxide for the instruments. It was obvious how much pride he took in the excellent job he did. He even made Julie and I take off our foot covers to walk outside with him to show us the roof pipes that carried away the carcinogenic ethylene oxide gas. Seeing how they re-use everything here makes us seem so wasteful at home when after a case at least two or three trash cans are brought in to the O.R. to cart away all the materials.
The afternon was spent watching small incision extra-capsular cataract surgery, something I have wanted to see for a long time! Because phacoemulsification is quite costly (the machine and the disposable tools), the small incision surgeries are more cost-effective and practical for most patients. The incision (8-9 mm) is almost three times the size of the one made in phacoemulsification (around 3 mm), but both surgeries can achieve excellent visual outcomes with low complication rates (though small-incision complication rates are higher than phaco due to the incision itself and the pressure placed on the vitreous body), so the manual small incision extra-capsular surgery is the preferred technique in developing countries like India where the cost of phaco is prohibitive for most patients. It was very interesting to watch him make the trans-conjunctival incision, followed by a three-plane U-shaped scleral incision. Then he carefully removed the nucleus and the cortex through the incision...voila! Very cool, and a surgery I want to learn how to do because I think it is vital to my desire to do ophthalmology in developing countries. Dr. Jeyanthan was again a wonderful teacher, allowing me to watch through the teaching microscope the whole time so I had stereopsis, which makes cataract surgery even more exciting when you can appreciate the depth and contours of the eye and the cataracts.
Most of our afternoon patients were camp patients, and they had some of the most mature cataracts I have ever seen, which makes them very difficult to remove. Because they are very poor and from such remote areas, they are often very malnourished and in poor health. One patient's eyes were so recessed from a combination of orbital fat atrophy with old age and her malnourished state that Dr. Jeyanthan had to do a lateral canthotomy to get better access to the eye to perform surgery. I asked Dr. Jeyanthan how the camp patients are able to get eye surgery, and he said that the government pays 650 rupees for each camp patient as well as pays for the lens. However, that's still not enough when a small-incision extracapsular cataract extraction is about 6, 500 to perform. I asked him how Schell is able to do these operations without losing money, and Dr. Jeyanthan explained that the ophthalmologists operate for free, and they also employ the "Robin Hood Policy".
"Sara, do you remember the first patient of the morning?" He asked.
"I do." I said, thinking of the bloodbath.
"Well, she was a paying patient and we used her leftover silk suture and some of the other materials she paid for in the little boy's surgery that immeadiately followed hers, because his mother couldn't pay and he needed the surgery."
Steal from the rich and give to the poor. I like the Robin Hood policy, and I like Dr. Jeyanthan.
So, suited up in our surgery attire, we met Michael down the hall who was dressed similarly, but in white scrubs (all the men wear white, the women blue). We then met Charles (I'm pretty sure that was his name, though I haven't met an Indian man named Charles here yet), who was the head nurse of the O.R. He gave us a nice tour of the eye O.R. which included 4 operating rooms (or theaters, as they're called here), one which was reserved for paying patients, and one that was reserved for camp patients. (Brief explanation of camp patients: Back in the 60's and 70's, ophthalmologists traveled to the rural villages to do screenings and performed surgeries in makeshit operating rooms (schools, homes, etc.). Obviously the conditions weren't exactly sterile, endophthalmitis was a frequent occurence as well as other complications, and the government started mandating certain operating outcomes and parameters for the eye surgery "camps". Needless to say, that shut many of them down but established better rules, regulations and patient safety, and now great eye hospitals like Schell and others exist. Ophthalmologists still go out to the rural villages, but only to perform vision screens and bring these indigent patients in who need surgery but can't afford to pay. Hence the term "camp patient" was born.)
Our first surgical case was with Dr. Jeyanthan, a young, very kind comprehensive ophthalmologist from Vellore whose special interest was in neuro ophthalmology. However this morning he was doing a dacrocystorhinostomy on a woman who had chronic complicated dacrocystitis with cutaneous fistulae formation. I have seen several at home at Dean McGee and felt comfortable walking into the procedure, but was quite surprised when I saw the large amount of blood (large for ophthalmology, not large for general surgery...Carla) during the case and even more surprised by the lack of pain medication and sedation for the patient. She had some local anaesthesia, but it had pretty much worn off by the middle of the case when things got quite complicated and Dr. Jeyanthan couldn't thread the punctal tubes through the ostomy in the nasal mucosa. I was trying not to cringe as the patient cried and groaned in pain in Tamil, and was relieved when the case was over. I have a very high tolerance for blood and guts at this point, but hearing a patient in pain makes my stomach churn. The next patient was having a similar procedure, but he was a darling boy of four years. He was not happy to be in the O.R. without his mother and struggled as they administered general anaesthesia (little kids can't hold still enough like adults can for these procedures), and I tried to calm him by talking to him and stroking his arm before he conked out. The procedure went much better this time, and Dr. Jeyanthan was an excellent teacher who made sure that Julie and I understood every step of the way. He answered all of my questions, and I left the operating room quite satisfied that I could now describe every step of the procedure, something I hadn't been able to do before.
I was extremely curious about how the sterilization of drapes, gowns and instruments were done here, because absolutely everything was recycled and re-used. In the U.S., all of the drapes, gowns, towels, etc. are disposable and thrown away after each use with a new package opened for each patient, no matter if they have insurance or not, can pay for the surgery or not. Because resources are so precious here, they re-use everything! Charles explained the lengthy autoclave cycle for linens and the gas sterilization method using ethylene oxide for the instruments. It was obvious how much pride he took in the excellent job he did. He even made Julie and I take off our foot covers to walk outside with him to show us the roof pipes that carried away the carcinogenic ethylene oxide gas. Seeing how they re-use everything here makes us seem so wasteful at home when after a case at least two or three trash cans are brought in to the O.R. to cart away all the materials.
The afternon was spent watching small incision extra-capsular cataract surgery, something I have wanted to see for a long time! Because phacoemulsification is quite costly (the machine and the disposable tools), the small incision surgeries are more cost-effective and practical for most patients. The incision (8-9 mm) is almost three times the size of the one made in phacoemulsification (around 3 mm), but both surgeries can achieve excellent visual outcomes with low complication rates (though small-incision complication rates are higher than phaco due to the incision itself and the pressure placed on the vitreous body), so the manual small incision extra-capsular surgery is the preferred technique in developing countries like India where the cost of phaco is prohibitive for most patients. It was very interesting to watch him make the trans-conjunctival incision, followed by a three-plane U-shaped scleral incision. Then he carefully removed the nucleus and the cortex through the incision...voila! Very cool, and a surgery I want to learn how to do because I think it is vital to my desire to do ophthalmology in developing countries. Dr. Jeyanthan was again a wonderful teacher, allowing me to watch through the teaching microscope the whole time so I had stereopsis, which makes cataract surgery even more exciting when you can appreciate the depth and contours of the eye and the cataracts.
Most of our afternoon patients were camp patients, and they had some of the most mature cataracts I have ever seen, which makes them very difficult to remove. Because they are very poor and from such remote areas, they are often very malnourished and in poor health. One patient's eyes were so recessed from a combination of orbital fat atrophy with old age and her malnourished state that Dr. Jeyanthan had to do a lateral canthotomy to get better access to the eye to perform surgery. I asked Dr. Jeyanthan how the camp patients are able to get eye surgery, and he said that the government pays 650 rupees for each camp patient as well as pays for the lens. However, that's still not enough when a small-incision extracapsular cataract extraction is about 6, 500 to perform. I asked him how Schell is able to do these operations without losing money, and Dr. Jeyanthan explained that the ophthalmologists operate for free, and they also employ the "Robin Hood Policy".
"Sara, do you remember the first patient of the morning?" He asked.
"I do." I said, thinking of the bloodbath.
"Well, she was a paying patient and we used her leftover silk suture and some of the other materials she paid for in the little boy's surgery that immeadiately followed hers, because his mother couldn't pay and he needed the surgery."
Steal from the rich and give to the poor. I like the Robin Hood policy, and I like Dr. Jeyanthan.
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