Coimbatore, India and Jakarta, Indonesia

By: Ameila Sorensen

Coimbatore, India

Ganga Hospital provides world-class orthopedic and plastic surgery care using ingenuity to overcome the difficulties with obtaining resources. Cost is central with the best care provided for the minimum cost. A free flap can be done with two small pans of instruments. The specialized paper drapes used in America are replaced with elegantly draped sterile sheets that are washed at the end of each case. Each suture opened only after requested and then used to the fullest extent. Even the air conditioner is only turned on when the room becomes too hot and then when the room is cool it is turned off. Dr. Hari said the hand / microsurgeons have to do 30 surgeries a day to meet their cost of operation. Orthopedics does around 50. They are hoping to keep expanding until 100 surgeries a day are done at the hospital.

Every patient is told how much their treatment will cost when they arrive. It is even on the consent. A surgery including preop admission, anesthesia, OR, recovery time in an ICU like specialized monitoring unit as well as on the general floor costs a few hundred dollars. While each patient got the same level of care in the OR, several levels of postoperative care were available. There was a general ward with 25 beds separated only by curtains or smaller rooms up to a private room with a TV.

A sense of family and family responsibility is very strong in India. I was in an elevator when a stretcher came in with at least 7 other people crowded around.
The family members provide the majority of perioperative care. One person is allowed to stay and if more stay then they pay the hospital extra. The entire family or even community helps to pay if someone needs surgery. There a few homeless people in India because a family no matter how cramped will make room for one more.

The majority of what I saw was trauma: crush injuries, closed and open fractures, amputated fingers/hands/limbs, burns, and degloving injuries all came through the door. The doctors said when there is an accident in Coimbatore people thank god they are alive and then tell the ambulance to take them to Ganga. The system for dealing with the traumas if one of well timed efficiency. When the hospital started there were 3 doctors – an orthopedic surgeon, a plastic surgeon and an anesthesiologist. When traumas came in often the surgeons couldn't leave the OR, so the anesthesiologist would go evaluate the patient and prepare them for the OR. This system has stayed in place. If the patient has a severe injury they are taken to a room just outside the plastic surgery OR and there an entire trauma code can be run. The doctors said it is the room in which the most lives have been saved in Coimbatore. If the patients have a mangled extremity a nerve block is immediately performed, so that the patient can be comfortable while waiting for the OR. If it is something that does not require emergency treatment then they are admitted and taken the next day. It is the same if a patient is seen in clinic and needs operative treatment, since many travel long distances. No one but the surgeons can say who is admitted or discharged and when.

 In the OR since almost all patients have a peripheral nerve block which makes their extremity numb they are usually awake. Somehow the patients just lie still for however long it takes for their surgery, sometimes watching, sometimes sleeping. I never saw anyone talk or move unless asked. Dr. Sabapathy said all he needs to do is tell the patients to lie still and be quite and they will do it. My attempts to explain why this would be difficult in America were met with disbelief.

However, I spent most of my time with my only patient being a rat who I knew would not survive the day. We watched Dr. Ackland's video from Louisville in the 70s/80s on which this course is based. My favorite part had to be the bluegrass interlude while he stitched a vessel. It started with the principles of microsurgery. Beginning with how to sit and hold the needle and place your hands. Practice on rubber gloves progressed to chicken legs the first day. The next day we started on the rat femoral arteries, which at first seemed hard, but then we tried veins, then a vein graft and finally a vein end to arterial side. By the last day my hands which could not even find themselves under the scope the first day were moving with a sort of quickness and confidence as I sutured 1mm vessels with needles smaller than a finger nail and suture thinner than my own strands of hair. After the course ended each day we would go watch Dr. Hari and Dr. Sabapathy operate seeing complex reconstructions, replants and free functioning muscle transfers. They seemed to be on fast-forward compared with my own pace.

During the course we took plenty of breaks as beginning microsurgeons must and spoke with two orthopedic surgeons from Bangladesh who were also there for the course over cups of Indian tea. They also did mostly trauma but wanted to be able to repair their own vessels since someone who could was not always available or came too late to save their patient’s limb. This realization helped to put in perspective how lucky I was to be coming to learn not because I had to do it, but because I wanted to do it.

The week at Ganga probably improved my skills and thought process as a surgeon more than any week since that first one as the trauma intern. Truly an amazing time.

Jakarta, Indonesia 

After the week at Ganga I took a series of small planes across the Bay of Bengal to Jakarta. Jakarta has a population of 10 million people and 28 million within the metro area. Nearly 40,000 people live in each square mile and they have exactly two pediatric orthopedics surgeons, one of which calls pediatrics his hobby since what he really does most of the time is joint replacement. The entire country with a population of 238 million has only 7 fulltime pediatric orthopedic surgeons. There are more pediatric orthopedic surgeons than that in St. Louis, which has population 1/100th the size.

However, they were not as overwhelmed as I thought they would be. Most Indonesians received their orthopedic care from “bonesetters.” They seemed to do everything from treating fractures to scoliosis. National Health Care is coming to Indonesia in 2014 and no one is sure what is going to happen then. For now the ability to pay had to be guaranteed before surgical care was delivered. Even patients who had insurance had to wait until the insurance carrier agreed. I spent one day in a private clinic that functioned much like a western hospital and another in their public hospital that had a packed waiting room.

Again the hospital rooms were leveled with general rooms of around 10 down to private rooms and the ICU was a massive room with people separated by sheets. There was a patient with spinal TB in the general ward. The residents said they saw so many patients with TB it wasn't possible to separate them. A patient with a tibial shaft fracture was being treated in cast because he could not afford the cost of a nail or even a plate. Patients were always admitted prior to surgery both for the logistical reasons of transport and OR time and also to make sure they were stable for sugery.

There were only 3 or 4 orthopedic operating rooms that could run each day at their main hospita
Even with surgeons and staff available for more there simply wasn't enough equipment. During a free fibula case they could not start the two portions simultaneously because they only had two tourniquets for all the ORs and one was already being used. The hospital did not own a power driver and one had to be rented if it was needed. Anesthesia was again primarily blocks. A pelvic fracture patient was given a spinal. As I watched him rolled on to his widened SI joint for the spinal I thought again of how no American patient would tolerate it. This patient had been waiting 9 days for his surgery, so made no complaints.
The 3rd year resident templated out what he or she thought would be needed and that was what they had to do the surgery. For a complex DDH case which would have had a whole series of plate choices and jigs at St. Louis Children’s, they had 4 LCP plates to choose from. I learned in Indoneisa that almost anything can be fixed with an LCP plate. They knew what the books said could be used and how to do that operation as well, but they also knew what they had and how to do what needed to be done.

The residents paid slightly more than $1000 a year to work at the hospital. They were all very well read, frequently quoting the main orthopedic textbook and reviewing it on their smart phones (they all had two since this was how the communicated with each other) before the surgery. The last 6 months they are free from clinical duties and spend it studying for boards and in teaching sessions with the attendings. Since pediatrics is not seen everywhere several residents from other programs where in Jakarta at the same time as me to learn from their head surgeon. They made a point of having me at these sessions and I was able to offer insight into our management of general orthopedic trauma, hand trauma and pediatrics. I gave a presentation on Slipped Capital Femoral Epiphysis which is seen more commonly in overweight children, something none of the residents had seen, but judging by all the McDonald’s in Jakarta and even a Dunkin Doughnuts inside the hospital I think they will be soon. It was incredibly rewarding to be able to teach as well as learn from the residents there.

The residents also had vast knowledge and skills as general surgeons. They spend an entire year doing general surgery procedures and continue to do some at night throughout their training. Even the interns had done appendectomies. This part of their training was compulsory because like the surgeons from Bangladesh they did not know if where they en
ded up practicing would have another surgeon to care for patients.

There were no women surgeons in India or Indonesia. In Indonesia they kept telling me about an interesting bone lengthening case, but the head of the department was doing it and since he was “traditional” and did not think women could or should be orthopedic surgeons they did not send me into that surgery. There were a few female residents in Indonesia. One was assigned to “accompany me where ever I wished to go.” I gave her as much encouragement as I could during my stay and urged her to come visit our program.

In reading through what I have written I comment most on what they did not have which was in sharp contrast to everything we have here. However there was no lack of hardworking people who had joy in being surgeons. I was impressed by everyone in both places dedication and creativity from starting a free flap at 4pm to using their cell phone lights for bedside dressing changes. The whole trip made me feel lucky not only to live in America, but also to be a surgeon here who is treated as an equal to the male residents, can change her mind during surgery about implants, call for another driver or set if something is missing or broken, and operate on anyone who needs it.

Unlike some other countries I have visited where I am glad to have seen them, but have not made plans to return, I am already thinking of how I can come back to India and Indonesia and join these talented surgeons again.

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 (http://www.gangahospital.com/microsurgery/new/institute.html). 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.