Surgical Assembly Line…

…I don’t know how, but the days just keep getting more incredible here. The highlight of today’s hospital work was observing two general surgeons perform simultaneous, side-by-side, and back-to-back laparoscopic tubal ligations to a seemingly endless flow of women. To give you an idea of the pace of work being performed, one of the surgeons said he can perform 110 tubectomies per day just by himself! Wow!

In an operating room where a C-section had just been performed, placenta still sat in a bag on the bloody floor, and newborn child lay crying under a heater in the corner, the female patients would walk in barefoot and lay down on the vacant of two adjacent declined tables. Having been already given local anesthetic in the hallway, the women who entered were ready to go. As soon as their backs hit the tables, the abdomen was prepped with iodine and a single small incision was made below the navel. Instead of inflating the abdomen with CO2 as is typical, a nurse or technician would just keep stepping on a bag valve mask that had been modified to pump ambient air through a tube into the peritoneal cavity.

One technician stood between the heads of the two patients and was entirely devoted to sterilization of equipment. The doctors would turn to him, obtain a clean laparoscope, dexterously insert it into the patient, look through the small eyepiece, and with a few wiggles and pulls of the trigger clamp both of the Fallopian tubes. As soon as the doctor pulled out the laparoscope, the fully conscious patients would deflate like party balloons. A nurse would hustle over and suture the wound. Then, the patient would be pushed up to her feet so she could walk out of the OT under her own power. The next patient would be waiting next to the door, walk in, and take her turn. Most surgeries took about two minutes; no patient was in the OT for more than four or five.

–Patient walking out of the OT–

You might remember from a previous post that the women are actually paid for having a tubectomy in India. Each of the patients who walked out of the room was eligible to receive Rs 250 ($5) as an incentive to help voluntarily control population growth.

The med student I was with and I looked at each other in amazement at what was happening in front of us. In America, we perform procedures with tight regulations, extreme sterilization, and with little regard for expense. The exact opposite is true here. The surgeons don’t even know who the patients are. The patients almost never speak and do not seem to expect any comfort or special treatment just because they are having a surgery.

THIS is medicine on a scale and budget we cannot comprehend in America. As much as we might like to impose our values, ethics, and ideals on this society, it would simply never work here. Constraints of budget and resources coupled with the sheer quantity of patients prohibit any kind of care that we are accustomed to in the first-world. These patients are not here to be cosseted or comforted; chances are they’ve never received such treatment in their entire lives. They’re here to get done what they need done, that’s it.

–Boy waiting for his frenotomy–

We also observed eight surgeries performed by the ENT surgeon, including two septoplasties (to correct deviated nasal septums), two tympanic membrane TCA cauterizations, and multiple frenotomies (to correct ankyloglossia, better known as tongue tied).

–For only having topical anesthesia, he was a trooper!–

–Walking barefoot out of the OT–

–We joked, calling out “Next patient!” We never had to wait long–

–Operating on a patient with a deviated septum–

–Another frenotomy–

The photo above is one of my favorites of the day. It is of a patient holding a syringe full of his own puss from a swollen lymph node while being bandaged on the operating table and simultaneously being given discharge papers and instructions of where to take the sample. The rest of the country might do things slowly, but not here.

–Prepping a patient for a TCA cauterization of her ruptured tympanic membrane–

–Yet another frenotomy…but this time without any anesthesia–

–Ten seconds later–

–Surgical tools waiting to be used on any patient that needs them–

–Workers push starting the “Advance Life Support” ambulance–

What an eye-popping experience! As someone interested in a career in medicine, I cannot think of anything that could be more raw than today. This is medicine without the human aspect, almost as if patients were cars needing oil changes. However, there is a simplicity and effectiveness of it all that is actually, in a way, quite elegant. Some problems just aren’t as complicated as we think they are.