My fourth trip to Nanakpur but my first in a hospital setting. We had five cases posted for the day: open inguinal hernia repair; open cholecystectomy; renal stone removal; bladder stone removal; and diagnostic cystoscopy.
The surgeon arrived at 9 AM, asked for the list of patients and began to order the cases based on complexity and tool requirements. This was different from the U.S. where elective cases were scheduled for a time slot. The first patient was already in the OR getting prepped but the anesthetist was unable to gain access. Instead of using an ultrasound to find the vessel, the anesthetist told the patient to to return after two of the other cases. The surgeon had to complete all 5 cases before the staff left at 2 PM and did not have the luxury of time.
We moved on. The next patient walked himself to the table and laid on his left side so the anesthetist could administer spinal anesthesia. Within 45 minutes, the surgeon had completed the nephrolithotomy with nephroplasty, began the next case, and the patient even walked himself to recovery thirty minutes later. I had never seen a postoperative patient walk himself anywhere immediately after surgery. I was shocked.
However, these sort of surprises were expected based on my previous experiences in Nanakpur. In 2015 as second year medical students, Varshini Cherukupalli, a now soon-to-be surgical intern and co-founder of our work in Nanakpur, and I completed a population-based surgical needs assessment and a surgical and trauma capacities assessment of the community and healthcare facilities in Nanakpur, India. We quantified Nanakpur’s shortage of surgical personnel and procedures at lower-level facilities and determined that patients’ limited access to higher-level facilities was due to a lack of transportation. Based off our assessments, we concluded that there was a need to reallocate resources to lower-level facilities to increase access to surgical care. I would later realize that our survey-based conclusions did not factor in how the healthcare system operated in Nanakpur.
In 2018, I returned to Nanakpur to complete a surgical rotation at two of the public hospitals. The rotation was very different from anything I expected. The time I spent allowed me to complete the picture of surgical and healthcare access in Nanakpur. In 2015, the assessment I performed showed a lack of general anesthesia at the lower-level public hospitals, but my rotation revealed most of the procedures could be completed with spinal anesthesia. The population survey from 2015 underscored the financial difficulty patients experienced while waiting at the hospital without knowing the exact time of their procedures or appointments. While working with the surgeon, I learned the lack of pre-scheduling allows flexibility to make changes in order to complete all the cases in the shortened workday. The surgeons were not confined by their limited resources and shortened operative day. The ability to continue to strengthen the surgical and trauma capacities of Nanakpur requires insight into a unique healthcare system and an understanding of the community’s perception of healthcare, the availability and use of resources, and the surgeons’ skill set. In order to improve a system, one must have truly a complete understanding of all perspectives, so as not to undo the balance, meticulously maintained, but instead amplify the strengths inherently present.
Manisha Bhatia is a fourth-year medical student from Texas Tech University Health Sciences Center. She started her work in Nanakpur as a co-founder of the Northwestern University chapter of Project RISHI (Rural India Social and Health Improvement), an undergraduate organization dedicated to working with rural community partners to develop sustainable health solutions. Her passion for global health stems from empowering the individual to help the community. She will begin her General Surgery Residency July 2018 at Indiana University and plans to continue improving access to surgery globally. @manishab917
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