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.

4 thoughts on “Surgical Assembly Line…

  1. John- This is fascinating. Thanks for your excellent coverage of your experiences there. It really is great to see “Transplanted” in my inbox each day.

    I am curious about this mass-production style of surgeries. It does seem efficient but I wonder how often things go wrong. Did you see any procedures where something went wrong? I don’t grasp what led up to the line of pepople coming in to have the procedures done. How often are there instances where someone comes in to have their deviated septum fixed and they end up with their tubes tied?

    Be well!

    • Hi Chops!

      I’m glad you’re enjoying it so much! It’s a treat for me to put up posts too because it helps me grasp what I am seeing and experiencing each day. And, thanks to comments like yours, I know friends and family back home are engaged, entertained, and learning from it all, which is honestly just as rewarding to me.

      You’ve raised some great points. I got a good laugh out of your last question. I have not personally seen anything go “wrong” in the way you mean. Many things about the whole situation, however, are inherently “wrong” from a first-world standpoint. To be honest, I don’t think they even keep statistics on things like botched surgeries. All of the record keeping is done by hand in notebooks. Such records, as far as I can tell, only record which doctor did which type of surgery. It would be enormously difficult to compile the necessary data to answer specific questions like this. To make the question even more difficult to answer, I can almost guarantee there are no post-op follow up or check-ins. If complications did develop, patients would probably try to fight it for as long as possible on their own, especially if they don’t know what to expect as far as pain and healing time. Even in blatant malpractice cases, the patients here would have to file suits against the government, which would be far too laborious and expensive considering the patients who come here are the poorest of the poor.

      I must say, however, that the doctors are incredibly skilled. One thing is certain: they are experienced. Although I personally wouldn’t want to have an operation in this OT, I would definitely trust these doctors to operate on me in a more sterile setting.

      The women are all lined up outside because the government pays them to get their tubes tied (and they obviously don’t want any more kids). It seems to be a well-known option for women. I’m guessing that they are given ample education about the procedure during pre and post-natal check-ups. The patients do come in a particular order, however. Sometimes, a staff member would come into the OT to ask the patient’s name so he or she could check it off of the rolls. Men can also receive government kickbacks for having a vasectomy: a whopping Rs 1100 ($22).

      Great to hear from you Chops! Thanks again. Best wishes,

  2. John,
    I am enjoying your blog. I just signed up today on the “Follow Me”. It is almost like a mini vacation each day from my tedious (sometimes) routine. I have shared your blog with two of my education classes and several colleagues at the college. Here is a reply from one: “Thank you so much for this link, Susan. I’ll share this blog with my family. I think I may share it with the India Program too. I’ll link it to the TnCIS India page on Facebook.” My education classes are excited about participating in a Service learning project and helping by sending supplies and/or money. Could you give me a little more direction on how we can help? Many of the students are now following your blog. It would be exciting if they could send materials or money and see how it is used with photos in your blog before you leave.

    • Hi Mrs. Brandt,

      Thanks so much for you patience. I’ve been hard at work on plans for a great way to get everyone involved. Today’s blog contains the first of many education statistics to come. Money certainly goes a long way here and will likely be the preferred medium of donation. I am working on ways to provide continued and individualized support for many years with what is, to most Americans, a relatively small amount of money. I’ll let you know more as it develops over the next few days. I’m setting up accounts and determining the best ways to route funds as well. I will strive to make all donations and efforts as personalized and special as possible (for both the donor and recipient).

      Talk to you soon!

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