Surgery Camp

As previously mentioned, I decided to forgo the trip to Nagpur last Saturday, July 17th. Because I stuck around campus I was able to observe the first day of the surgery camp that would be lasting for three days. Witnessing the surgeries in the clinic was a very big bonus on top of the work that I am doing at SEARCH, and in many ways unrelated. It is entirely clinical, not for research purposes, and the spinal surgery that was occurring is in no way related to my research focus. However, I found the experience to be extremely fulfilling.

Each year SEARCH organizes and holds several surgery camps. Since the hospital itself primarily deals with medical care and medical interventions, and Ama is a gynecologist/obstetrician by training, there are limited opportunities and resources for surgical interventions. Therefore, several times each year SEARCH brings in highly-trained surgeons, who bring along supplemental equipment, and villagers on a waiting list come and have surgeries. The structure of a surgery camp (often occurring in places of natural disaster, like Haiti, or refugee camps or parts of the developing world) is efficient because a team of surgeons will come in and perform the same surgery over and over. Supplies and equipment that are often not available will become concentrated in the location for the duration of the camp. Earlier in the summer SEARCH held a surgery camp for hysterectomies where over 100 patients were seen in one week!

The surgery camp that took place this past Saturday to Monday was for spinal surgery. The number one surgeon for spinal surgery in India, the premier surgeon in India for this type of surgery, Dr. Shekhar Bhojraj would be in attendance. For Jessica this was a very big deal. She is hoping to go into surgery and work in third world countries. This summer she is starting a research project to assess unmet surgical need.

During breakfast on Saturday I asked Jessica if she thought it was too late to see if I could observe the camp and she said not at all! I went over to the hospital with her in the morning to review the records of the camp's patients alongside Vaibhav, one of the Ayurvedic doctors. Later in the afternoon the team of surgeons arrived from Mumbai, headed up by Dr. Bhojraj. His wife is an anesthesiologist who would also be working on all the surgeries. There were at least four or five other orthopedic surgeons that came to SEARCH. This was not Dr. Bhojraj's first visit to SEARCH. He has been coming here several times a year for the last several years. I went around with the surgeons to meet each of the patients. Four women sat in one room and three men in another. There were seven in total, plus a few walk-ins. All the patients were dressed in green hospital outfits and each had a set of x-rays. I tried to stay out of the way because it was a very large group parading around- all the doctors, a team of aides and nurses, Ama, Vaibhav, Jessica, and myself. Not only were the patients waiting with some of their family members in rooms with no privacy, but then in walks over 15 people to assess their situations! I think Dr. Bhojraj had already reviewed the cases before meeting the patients because things moved pretty quickly. One or two of the patients were told that they may not be able to have surgery because of existing complications. I know this is normal procedure, and happens all the time in the U.S. as well, but I felt bad for the patients because to even be at SEARCH for the surgery camp means the patient has exhausted all medical interventions, survived a waiting list, and anticipated the scheduled camp.

After meeting the patients, the doctors broke away for lunch. Around 2pm we reconvened to start the surgeries. At this point I was still unsure if I was going to be allowed to stay or not. Since I had not received prior permission from Ama, I was very sure I would be kicked out of the operating room, or operating theater, as they call it here. The plan was to conduct two surgeries at once in the one OT that SEARCH has available. All the doctors started dressing in scrubs and masks and scrubbing in. Since Jessica was definitely going to be observing the surgeries, and possibly assisting, she asked if she should go back to her room and put on the scrubs she brought with her from Duke. Very generously, since it looked like I was not going to be kicked out, she brought me with her and gave me a pair of scrubs to wear as well.

Pause...I'm having doubts if I should continue my description of the surgical camp because I think I am going to severely disappoint those family members, who will remain nameless, who have always wanted me to go to medical school...but alas, I will continue.

I put on a green pair of scrubs and when Jessica and I returned to the OT we put on the personal protective equipment: masks and surgeon's cap. I didn't get a chance to take a photo of myself in this getup, but believe me, I looked legit. I felt like I was playing dress-up, but for Jessica this was real life, so I tried to take everything seriously. If anyone really really really wants to see me look like a doctor (the MD kind), I can maybe ask Jessica if I can borrow her scrubs again, and go grab a mask and cap from the clinic, and re-stage the event. We chose not to take any photos of the actual surgery, although the scene was amazing, out of respect for the patients (who were completely naked), and obviously the surgeons who were trying to focus.

Anyway, surgery camp began. This is what it was like: We had two operating tables with a table in the middle that was used to anesthetize the patient before they were moved to the operating table. Dr. Bhojraj decided the order in which the patients would be seen. A team of three surgeons worked at each table, and each surgery would take 1-2 hours. In addition to the six surgeons, there was Dr. Bjojraj's wife and a second anesthesiologist, several surgical nurses from SEARCH, Jessica, myself, at times Vaibhav, and even SEARCH's handyman at one point when the bulb blew out on the operating light. We were all crammed into a room that was roughly 15x15 feet. It was insane.

As the surgeries began I asked Jessica what the major differences were between the surgeries we were witnessing and the ones she had witnessed at home. The most obvious difference was the fact that two patients would be operated on in the same room. Next, not all of the equipment and tools that could potentially be used in these surgeries were available. Now, SEARCH itself has pretty modern capabilities, and this isn't one of those hospitals you hear about that reuses needles and uses unsterilized equipment. Because of proper training and funding that allows the purchase of proper equipment, the surgeries used completely sterilized draping sheets and surgical tools. But in many ways there were small differences. For instance, the anesthesiologist had to use a manual ventilator for the entire duration of the surgery which meant squeezing one of those rubber balls, the size of a soccer ball, every five seconds for the 1-2 hours of the surgery. In a completely modern, state-of-the-art hospital this would be done automatically with a machine. Another example is that because this was back surgery, the patients were lying front down, but propped up by cylindrical foam pillows. The patients were put directly onto these pillows and the pillows were reused between surgeries with no cleaning. So maybe not everything was 100% completely sterile. I think there were other ways in which the doctors had to make-do with available resources, but not being formally trained, and not having witnessed surgery before, I am unsure of what these things were.

Beyond these differences, the surgery happened as it would in any other modern institution. The actual anatomy of the surgery was not much of a surprise to me. I was prepared to see someone cut open and to see blood, and because of dissecting cats in physiology, and of course television, I had a rough idea of what the insides of a body were going to look like. The surgeons used blades and electric cauterization to open the layers of the skin, muscle, and fat. I was really surprised by how deep the surgeons had to go to get to the vertebrae and the spinal cord. The first cut into the body was not weird to me, and neither was the initial depth of a couple centimeters, but halfway through the surgery I realized that we were a good inch or two inside the person's body cavity. This was somewhat amazing.

Also to note, I was very very close to the action. For most of the surgery I was probably one to two feet from the surgical table and I could see everything! I could have stood right at the table, but I found out that while blood doesn't bother me, tiny pieces of spine falling and flying everywhere does. I really did not want to be touched by pieces of what used to be the inside of someone's body, despite wearing the scrubs.

When the doctors were deep enough they used surgical techniques that Jessica explained to be during lunch to remove parts of the spine to allow more room for the spinal cord. Most of the patients were suffering from pain and neurological issues related to reduced space in the spinal canal. The type of surgery I watched is called a laminectomy. This is when parts of the spine are removed to relieve pressure on the spinal cord. One of the techniques removes only the spinous process, which is the part of the vertebrae that you feel when you run your hand down you back. A second technique also cuts into the articular facets to create even more room. The parts of the spine were removed with special tools that had the ability to cut through the spine. At some points Dr. Bhojraj also had to use a hammer type tool. Something else that really surprised me was the aggression and force that were used to remove sections of the spine. There were parts of the surgery where I found it very hard to believe that a real person was lying under the sheets.

At the most critical parts of the surgery I was able to see the spinal cord. Again, seeing the spinal cord of a dead animal does not compare to seeing a live spinal cord of a person, who except for anesthesia, is completely alive in front of you. Jessica was really having a good time and thought the whole surgery was "beautiful" and Dr. Bhojraj's techniques were "elegant" and "like watching art." I don't think I appreciated what I was seeing to the extent that she did, but I was still really in awe.

During the surgery I had a couple chances to speak with Dr. Bhojraj's wife, the anesthesiologist about anesthesia. This was the aspect of the surgery that amazed me more than anything. I just could not get over the fact that the surgeons were doing things to a human being, that if they were alert and conscious they would be screaming and perhaps passing out in pain. The initial cut and separation of the skin and tissues alone would be incredibly painful for someone, but we were also cutting away and yanking on vertebrae, and deep tissues, and I'm pretty sure some of the tools were gracing the spinal cord. I still don't get how even the strongest anesthesia can keep someone from feeling this.

I mainly watched the surgery that Dr. Bhojraj conducted (the second patient to start), even though there was another one being conducted at the other table a few feet away. When the other team finished with the first patient, they prepared to start on the third patient. Here is another difference between the surgeries I witnessed and ones that would take place elsewhere. The staff actually had the third patient come into the OT, while the second patient was still being operated on. Let me just paint this picture for you. A middle-aged women walked into the OT, about to undergo anesthesia and invasive surgery, and the first thing she sees is a naked woman lying with her back up in the air with a huge gaping opening. To Dr. Bhojraj's defense, he was not told the next patient was coming into the room, and he expressed that if he did know, he would have at least stopped his actions for a few moments. Since I was closest to the door when the patient came into the room, I tried to shield her eyes from the operation that was underway and guide her over to the anesthesiologist waiting at the second table. Hopefully I was able to block her view, but she still seemed very scared.

I spent some time watching the first woman recover from surgery. When she was done, but still under anesthesia, they moved her out to the recovery room. She woke up at several points, but not enough to really talk or communicate. During these moments though, I realized I was very very interested in the follow-up that would occur in the minutes, hours, days, and weeks after the surgery, probably just as much so as the surgery itself. I peeked over and watched the surgeons as they waited by the bedside for the patient to become conscious. I was very drawn to this part of the process.

When Dr. Bhojraj finished his patient I decided to call it a day and not stay around to watch the third and fourth patients. I felt like I had seen my share of the surgeries, and I still could not believe that I was able to stay for as long and as close as I did. Since I have not been to medical school, I knew the other surgeries would all appear roughly the same, and I felt I had seen enough blood and body parts for one day. Jessica of course would be staying for the rest of the day, especially because Dr. Bhojraj asked her to actually assist in the last surgery. I didn't stick around to see this, but I think this was a wonderful experience for her.

So, that was surgery camp. I'm not sure if I will ever get the chance to witness something like that in the United States, and again, this wasn't really within the realm of my research areas, but it was still a truly inspiring experience. I have yet to get over the fact that humans have been able to reach this level of technology and knowledge.