Thursday, May 21, 2015

Coimbatore, India

By: Claire Manske, MD

The busy city of Coimbatore

For my international rotation, I traveled to Coimbatore, India to participate in a microsurgery course and observe the plastic and orthopedic hand surgeons at Ganga Hospital. Coimbatore is in the Southern Indian province of Tamil Nadu. It is the sixteenth largest city in India and the second largest city in Tamil Nadu. It is known as the Manchester of South India, given its prominence in the textile industry, which is facilitated by the surrounding cotton fields. Engineering, health care, and information technology are also emerging as primary industries in the region. Given the proximity to the equator (Coimbatore is at the same latitude as Cental America), I assumed it would be hot and humid when I visited at the beginning of September. However, I was incredibly pleased to experience the temperate climate that Coimbatore is afforded by the protection of the Ghat mountain range.

Ganga Hospital
Ganga Hospital, located near the center of this bustling city, is one of the largest and busiest orthopedic and plastic surgery specialty hospitals in India with 450 patients beds. It is a tertiary care center for trauma, orthopedics, and plastic and reconstructive surgery. Given its reputation, patients come from throughout Asia, the Middle East, and Africa to be treated here, and physicians come from across the globe to train here. Dr. Raja Sabapathy, a master plastic surgeon, is the Director and Head of Plastic Surgery at Ganga Hospital, which was founded by his father. Along with his colleagues, Dr. Hari Venkatramani, Dr. Paveen Bhardwaj and the other orthopedic and plastic “consultants,” Ganga Hospital treats a high volume of severe and complex problems of the hand and limbs.

My first week in India, I participated in the microsurgery course at the hospital’s Microsurgery Training Institute. The course, taught by Mr. Ravi Kumar (a master surgeon of rat microsurgery), follows the method of Dr. Ackland of the University of Louisville.  

Each day we began the course by watching an instructional video from Dr. Ackland, followed by applying our newly learned skills on our rats.  In the course of a week, I learned how to primarily repair rat femoral arteries and veins, how to treat segmental vascular defects with an interpositional vein graft, and how to perform an end to side arterial anastomosis.  It is amazing how quickly my microsurgery skills improved when I was able to concentrate exclusively on microsurgery and with Ravi’s careful guidance and patience. A rat’s femoral arteries and veins are approximately 1mm in diameter, and therefore, about the caliber of the digital vessels at the level of the distal interphalangeal joint.  Being able to perform microsurgery on such small vessels gives me a lot of confidence heading into digital replants and revascularizations as a fellow next year.

Among the most impressive injuries that I saw was a bangle avulsion injury, akin to the ring avulsion injuries I have seen in the United States. Evidently the incidence of this injury is sufficiently high, that the consultants at Ganga published their experience with this injury in JHS (E). The patient I saw was a thirty-three year old female factory worker whose bangle was caught in a machine at the factory were she worked. She suffered a traumatic amputation at the level of the distal forearm, a segmental radius fracture, and a radiocarpal dislocation. After shortening her radius, converting her to a one bone forearm, performing a radiocarpal fusion, and primarily repairing of her radial and ulnar arteries and ulnar and medial nerve, she had a reasonable looking and well perfused upper extremity. 

In addition to replantations and revascularization procedures, I observed Dr. Sabapathy and his colleagues manage soft tissue defects of various etiologies.  I saw numerous, anterolateral thigh, soleus, sural, and peroneus brevis flaps. I was also able to observe free gracilis transfers  to restore elbow flexion brachial plexus injuries and to provide finger flexion following Volkmann’s contracture incurred following a supracondylar humerus fractures in children.

Finally, I observed free phalanx transfer from the toes to the fingers in a patient with symbrachydactyly, a procedure that is less commonly performed in the United States (and certainly at Washington University) but is the treatment of choice at Ganga Hospital.

International Trainees

Dr. Sabapathy and Dr. Venkatramani with the international trainees
In addition to working with Dr. Sabapathy and his colleges, I was fortunate to have the opportunity to meet and learn from the Indian residents at Ganga and several international trainees.  We would meet each morning during lectures and discuss common pathologies and the different treatment methods performed in our home countries and institutions. From these interactions, I gained greater insight into global health and medical practice, and developed an appreciation for the resources available in the United States, as well as making several good friends.

I feel incredibly privileged and grateful for the incredible opportunity provided by this residency program to travel abroad and experience how medicine and orthopedics are practiced internationally.  This really is a transformative experience; the technical skills I gained, the decision-making process I observed and participated in, and the insights and friendships I developed has changed my career.

No comments: