Pauri

Part of our second week in Dehradun was spent with Dr. Ramola who is an ophthalmologist. He spent his early career working for a government hospital and performed over 40,000 surgeries while working there. Now, he spends his time running a much slower paced clinic, operates only once a week, and spends the rest of the week following up on the week’s surgical patients as well as seeing walk-in patients. A few times a month he will travel to rural villages around Dehradun to perform cataract surgeries. We were fortunate enough to be able to go with him on one of these weekends to a “health camp” and see what it is like to perform cataract surgery in a very rural setting. The destination for our health camp was a town named Pauri which is a five hour drive from a Dehradun on winding mountain roads. The views on the drive were spectacular, however it might’ve been the worst car ride of my life. The night prior we were attended a Lohri celebration where we indulged in many Punjabi delicacies and consequently were paying the price for our gastronomic indiscretion.  All four of us were afflicted with terrible G.I. symptoms which, naturally, made for an interesting (i.e. miserable) car ride to Pauri. Despite our struggles, we did make it to Pauri……. just a little bit worse for the wear. Alas….. I digress……

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A mountain town above the river Ganges along the way to Pauri.

Pauri is one of the oldest mountain settlements in India and has a population of about 30,000. The hospital we went to had two buildings near the center of town. One building contained the casualty room (ER) and inpatient wards while the other held the clinics and the operating theaters. Literally as soon as we arrived, we were rushed to the casualty room to see a patient who’d just come in. The poor woman was about 70 years old and had fallen into a fire and sustained burns to her right hand, forearm, and chest. As it turns out, she fell into a fire because she was almost completely blind due to significant bilateral cataracts. Apparently this is not all that uncommon of a situation and there are lots of burns cases each year due to blind patients falling in fires. This again serves as a reminder of how large of an impact vision impairment can have and how huge of a change you can make in a patient’s life if you are able to restore any degree of sight. After seeing the burn patient, we went with Dr. Ramola to the optho clinic room where he briefly examined the 15 patients to be operated on that day. To make the health camps more efficient there is a local optometrist who screens and preps all the patients prior to surgery. All Dr. Ramola has to do is show up, confirm the findings, and perform the cataract surgery (which sounds like a pretty sweet gig to me).

Now, for anybody who knows me, eyes are one of the very few things in medicine that weird me out. Because of this I was simultaneously anxious and excited for the chance to observe cataract surgery as I’m still working to get over my discomfort around the eyeball. Many people in the US opt for laser repair when they have cataracts, however, that is not an option in the rural regions of India (apparently, manual lens replacement also offers better long term outcomes). Given the rurality and his preference, he still performs old-school cataract surgery with manual lens replacement. As someone who never seen a cataract surgery before I was blown away by the procedure. He started with a small incision lateral to the iris, worked his way inside, reflected the anterior chamber, popped out the old, cloudy, solidified lens (which would make a solid “clunk” sound when it was discarded in the metal waste-bin), inserted an artificial lens and the surgery was over. Literally, within 15 minutes he had restored sight to a patient who was otherwise blind. Talk about amazing!

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The ED and general wards on the left and the clinics and ORs on the right.

As a final commentary about this experience let me describe for you the conditions of the operating theater…… since they were suboptimal to say the least. If you’ve ever been in an OR in the United States you will know how meticulously clean and sterile of an environment it is. This is certainly not the case in rural India. The hospital had two operating rooms of which only one was functional (thank goodness). The non-functional OR was an old, dusty room with a table in the center. The ceilings were moldy, the paint on the walls peeling, and the floors were covered in plaster crumbs. I would have hardly considered the room fit for a clinic visit yet alone good enough for an operation. Thankfully, this was not the room we used for the cataract surgeries and the actual OR was right next-door.  Unfortunately…. the situation wasn’t much better as the floors were still super dusty but at least the ceiling and walls were intact with no sign of mold or crumbling plaster. Continuing with the theme of odd juxtapositions, it was funny to see relatively modern operating equipment in the center of this otherwise dingy room. We asked Dr. Ramola about the conditions, and he admitted that they were less than ideal (bordering on terrible). He didn’t want to operate under these conditions, but had no choice given the available resources. In the end, it was far better to perform the surgeries (albeit at a higher risk) than to not do so given the tremendous benefits they offer.

 

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OR # 1…… only slightly terrifying.

 

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OR #2 …… a slight improvement

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Everyone geared up and ready to remove some cataracts!

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