Grantee Project Summary- A Humanitarian Trip to India

Samit Sunny Roy, MD, MSPH

Touching down in India I didn’t know what to expect. I had never been to India before, let alone to work as a doctor. Upon arriving in Bhopal, I was greeted at the airport by staff from the hospital. In the car as we began heading to the hospital my mind was racing. There was a mixed sense of uneasiness at not knowing what lay before me as well as excitement at the prospect of a new adventure. I was given a tour of the hospital on my first day and told that while I was here as part of the urology camp, that the hospital was an ophthalmologic hospital. While much of the staff would be volunteers from the hospital, surgical technologists and OR staff would be volunteers from around India who were more familiar with urology instruments and procedures. As I began taking in my surroundings, I noticed that an administrative area had been converted to preoperative and postoperative recovery areas with dozens of mobile cots. There were three operating rooms at the end of a small hallway where we would be operating. My first two days would be spent in the clinic assisting with preoperative assessment. The clinic was in a makeshift area separated by a sheet, with a small table and a few plastic chairs. Another sheet separated the “physical exam” area with a small cot. I was paired with a veteran Indian urologist, Dr. Dewani, who had been involved with these urology camps since they began. He explained to me that the patients we would be seeing had mostly already been assessed by a local general practice physician. We saw 45 patients that afternoon. I was immediately struck by several differences in the practice patterns between the USA and India. First, there is no electronic health record. Patients are responsible for keeping their own medical records and bringing them to their visits. I was impressed by the efficiency that resulted from no cumbersome documentation requirements. It really underscored how much time in my typical day I spend documenting, charting, and putting in orders rather than participating in patient care. It was almost unbelievable to me that most medical records were written in English even though none of the patients spoke English. I kept thinking how much outrage there would be if American’s medical records were in Chinese or Russian. Lastly, I was intrigued by the different medical calculus involved in patient decision making for surgery. A lot of these patients had not tried medical therapy but given the socioeconomic limitations and lack of access to pharmacotherapy, many patients were directly booked for surgery as a more definitive treatment option. It was an interesting detour from the traditional western paradigm of initial conservative to more invasive treatment progression. After two days in the clinic, I was ready to experience the second half of my experience in the operating room.

On the evening of my second night in Bhopal, the attending urologists arrived to prepare for operating the next day. There would be three attending urologists and myself operating over the next few days. Dr. Amlani and Dr. Mehta were two Indian urologists from a neighboring community along with my mentor from the USA, Dr. Singh. That night we reviewed all the cases and planned out the logistics for the next few days. Approximately 65 patients would be having surgery. Two of the three ORs were capacious enough to have two tables running at a time. One room was significantly smaller and only able to accommodate one patient at a time. One OR would be specifically for transurethral resections of the prostate (TURPs) and direct vision internal urethrotomy (DVIU) procedures. Approximately half of the patients undergoing surgery would be having one of these two procedures so it would be a continuously running room. The other room would be split between one table reserved for percutaneous nephrolithotomy (PCNL) procedures and ureteroscopic stone extraction (USE) procedures. The last table would be reserved for urethroplasties and other more rare procedures that were lined up, including an open pyeloplasty, hydrocelectomies, and an anterior colporrhaphy. While these were all procedures I was familiar with from my training in the United States, I was excited to see the differences.

As soon as we started operating, I was struck by the differences, both superficial and systematic, between operating in the US versus in India. Almost all patients underwent spinal anesthesia with only a handful undergoing general anesthesia. The entire OR staff wore disposable flip flops in the OR as the idea of shoe covers did not exist. The idea of these flip flops was that nothing would be tracked through the hospital as the flip flops were only to be worn in the OR. A large collection of everyone’s shoes sat patiently outside the OR hallway. My first case was a hydrocelectomy. The case went smoothly, but I noticed immediately that the instruments were an amalgam of various sizes and quality. There was a large tub of green liquid in the back of the room where a staff member would pull out instruments from the antiseptic solution before giving it to the OR staff for use. Many instruments were unavailable, and I quickly learned that I would need to get used to using what was available rather than the ideal instrument. My next case was a transurethral resection of the prostate. The staff were very excited to show me their new bipolar TURP equipment. I honestly felt immediately comfortable as the setup was fairly similar to our setup in the US. After several back-to-back TURPs, I was called next door to assist with an open pyeloplasty. After making our incision and dissecting out the relevant structures, the power in the entire OR went out. A backup generator roared to life and while we were waiting for electricity to return many of the nearby staff pulled out their cellphones for light so that we could proceed. The delay was only a minute or two, but it struck me how at ease everyone in the room was with what I thought was a very unexpected turn of events. After the pyeloplasty I was instructed to help Dr. Mehta with some endourology and nephrolithiasis cases. I was blown away at how fast he was able to obtain his own percutaneous access. He was equally blown away when I told him that in the US we often have interventional radiologists obtain our access prior to urologists performing a PCNL. It was as we were getting through these cases that I realized there were no flexible ureteroscopic instruments. Ureteroscopy in this setting meant rigid ureteroscopy only. As a result, their volume of ureteroscopy was lower than I would have expected. After two and a half long days in the OR, my time in Bhopal was quickly coming to an end and soon it was time to head back to the US.

There’s nothing like a full day of flights, layovers, shuttles, and car rides to allow for introspection. Over and over, I came back to the feeling of gratitude. In such a short amount of time I felt as though I experienced so much and had such an opportunity to grow. I don’t think I realized how often I reflexively act and being in India was like a jolt that made me re-examine every step of what I was doing. Being in such a different environment than what you’re used to has a unique way of simultaneously making you grateful for what you have while realizing how things could be better. I will forever be grateful for this once-in-a-lifetime opportunity to go abroad as a trainee and know it will be the foundation for future international medical experiences. “