Monday, January 9, 2012

Coimbatore India

By: C. Tate Hepper, MD

As a child, my twin brother and I used to joke we were going to dig our way straight through the center of the globe to India, or the other side of the world. This December I traveled there. Long flights are certainly not my idea of pleasure. However, the opportunity to travel halfway around the globe to Coimbatore, India and visit a world-renowned plastic hand surgeon was something I could not ignore. The additional opportunity to participate in a week long microsurgery course sweetened the deal to deliciousness.

Dr. Raja Sabapathy, a master surgeon, hospital administrator, and researcher, is the Director and Head of Plastic Surgery at Ganga Hospital, a 400-bed orthopedic and plastic surgery specialty hospital founded by his father. Ganga is located in the heart of Coimbatore, the “Manchester of South India”, so named for its bustling textile industry. Coimbatore is a tropical town of just over 2 million people in the southern province of Tamil Nadu. The weather in December, the heart of “winter”, was pleasant with high’s in the mid-80’s. Poverty is widespread. Rice is the staple food.

I quickly realized that India is an extremely diverse country with a multitude of languages and cultures. Trainees in Ganga Hospital hail from all areas of India, and therefore, speak different languages and dialects. Much to my delight, English serves as the common language of everyday communication in the hospital. English is also widely spoken in the community, although I still found it difficult to communicate. The people both in the hospital and in the community were astoundingly pleasant, warm and friendly.

The plastic surgery service at Ganga mainly treats traumatic extremity injuries, but they also have a vibrant diabetic foot clinic. The volume of trauma is astounding. Most of them come directly from Coimbatore but there are also patients seeking Dr. Sabapathy’s expertise who travel from around the country and internationally.

The volume of trauma doesn’t come as that much of a surprise after you spend a few minutes on the streets. The flow of traffic resembles a whitewater river consisting of hundreds of people riding two-wheelers (motorcycles and scooters) sans helmet and shoes intermixed with “autos”, small cars, trucks and overcrowded large buses. Many two-wheelers will have multiple riders clinging on. I saw a family of five with groceries on a single motorcycle! The “autos” are motorized open rickshaws powered by a very small engine that serve as taxis. A trip across town runs 100 rupees (~$2). Traffic laws, if they exist, are not obeyed. Industrial machines and farming equipment provide another steady supply of mangled extremities.

My first week was spent observing in clinics, operating theaters, and the physiotherapy department. I was joined by several other trainees from around the world. Also visiting were a Russian hand surgeon, a British plastic surgeon, a plastic surgeon trainee from Mumbai, and three hand surgery fellows from Hyderabad. There was much lively discussion and debate on appropriate management of certain patients.

The culture in India frowns deeply upon amputation. Therefore, nearly every mangled extremity is salvaged. Severe injuries that would not be salvaged in the States are reconstructed with multiple surgeries and physiotherapy. Common cases include debridement of acute injuries, replantation, soft tissue coverage, and reconstructive surgeries. There were 10 free flaps performed my first week! Devastating mangled extremities are routine and are therefore approached in a systematic manner. Nearly every fracture is treated with an external fixator or simple Kirschner wires.

Neuropathic diabetic foot ulcers are treated aggressively with soft tissue coverage including free tissue transfer. They also treat a large volume of patients with brachial plexus injuries with a combination of osteotomies, nerve grafting, nerve transfers, and tendon transfers depending on the situation. Overall, they have outstanding outcomes.

Anesthesia is critical to the success of any surgical team. Dr. Bhat and his team of anesthesiologists, nurse anesthetists and technicians are amazing. Each patient with an acute traumatic wound is brought directly from the ER to a holding area outside the operating suite. There they are evaluated by the plastic surgery resident and the anesthesiologist. After a quick survey of the injuries, an immediate block is performed. This allows x-rays and further physical exam to be performed without pain.

Once the work-up is complete, the patient is pushed directly into an open operating theater for immediate debridement, stabilization of fractures, and revascularization as needed. I never witnessed a failed block, or a surgeon waiting for appropriate anesthesia. Anesthesia is available around the clock to provide immediate regional anesthesia. Patients are kept awake for surgery. There is often dialogue between the surgeon and patient. The surgeons think it important that the patient witnesses their injury and treatment so they have reasonable post-operative expectations.

India is a country of striking contrast between rich and poor. Never was this more obvious than when standing in the largest operating theater of Ganga Hospital. One can stand near the window and observe a highly skilled team of nurses, anesthesiologists, and surgeons replant multiple digits in an exceedingly efficient, effective manner. Without moving one can glance out the window at the open market that bustles directly in front of the hospital. The market is constructed of discarded scrap metal and cardboard. The roof is strewn with trash and rotting, discarded produce. The aisles are littered with trash, animal feces, and the occasional stray dog looking for scraps. Most people don’t have access to clean drinking water.

Very few people in India have health insurance. Most pay cash for their care, and the level of care is determined by the patients’ means. Those that can afford it are provided a private room with air conditioning, a TV, and a nurse. Those of more meager means are placed in one of several large wards without AC and where family members serve as nursing care. The cost of care is negotiated in advance between Dr. Sabapathy and the patient. There is no pressure to discharge patients in a timely manner, and it is not uncommon for patients to be admitted for weeks or even months.

The second week I spent the majority of my time in the Ganga Microsurgery Training Institute ( The Institute is a state-of-the-art facility with four two-headed Zeiss microscopes and S&T microsurgical instruments. The course has trained over 400 trainees from all over India and 37 countries. The training program has been refined over several years and involves viewing videos by Dr. Aclund and practicing various skills on anesthetized rats under the direction of a seasoned instructor. This was an invaluable experience, which will make the transition to my hand fellowship less stressful and more educational.

Overall, my trip was an enlightening experience. I was exposed to a new culture. I gained an appreciation for the power of a well organized, efficient team of highly skilled clinicians working towards a common goal. I hopefully laid the ground work for a successful future career in microsurgery. I also learned that the only way to travel halfway around the world is in first class. Sitting in coach on a 16-hour flight is almost as bad as digging there.

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