March 19, 2021: Posted by One Surgery Admin
The following is the second in an exclusive three part series of extracts from the book, “My Kinwat Days”, written by Dr Arun Gadre, a gynecologist that has spent twenty years of his career serving the draught-prone rural population in Maharashtra, India. Dr Gadre is also an award winning author in the Marathi language, with 14 published books. In 1986, early in his career, he ventured to Kinwat, a village in India to set up a surgical service for the poor along with his wife, Jyoti, a practicing anaesthetist. In 1987, he left the project, feeling he had failed. “My Kinwat Days” are his memoirs, recalling his experiences there, and offers valuable lessons for the modern day global surgery movement.
Foreword (by Saqib Noor): Once again, I am extremely honoured and humbled to have Dr Gadre share his writings with us. This next chapter of Dr Gadre’s book, “My Kinwat Days”, highlights some of the challenges in global surgery beautifully in one elegant story – problems with obtaining hospital equipment, human resources, surgical training, ethical practice, and the life saving decisions that have to be made in such difficult circumstances. Although the literal English translation from Marathi does not do his deeply moving writings justice, I have tried my best to edit the direct grammatical translation throughout this three part extract series, whilst maintaining the fluidity and evocative style of Dr Gadre’s writings. I would like to personally thank Dr Gadre for being kind enough to share his wonderful writings and stories with us on the One.Surgery blog.
The first ever Caesarian section at Kinwat
The very reason for the escalating cost of my operation theatre at Kinwat was my insistence on optimal equipment. I did not want to compromise so I had an abundance of facilities. I had purchased an operation table for conducting deliveries of babies, I had general surgery and orthopedic instrument sets, and I had enough stock of medicines to last six months. Everything was optimum and ideal. Except the place.
There was a scarcity of good living and working places in Kinwat. As it was a township, many government offices were functioning from Kinwat as their head quarters.The Babu of government offices (the officers as they were called) had already grabbed whatever offices were available. And so very easily, the asking price for the rent was around two thousands. Reluctantly, I had to select for a thatched roof construction outside of the town as my hospital location, three km away. Once I got it, I made endless trips to Bombay and a nearby town (150km away) to purchase the required equipment. I used the available loan and finally, my dream came in to reality.
In villages, all tiny problems are magnified. There was no skilled electrician or carpenter. Whoever was available was illiterate. They certainly knew their trade but only grossly. However, I was pleasantly shocked when I applied for an oxygen cylinder. Indian Oxygen was a government run monopoly which supplied the oxygen cylinders for medicinal use. So naturally I expected typical government attitudes at their office. I met the official at an office in Bombay and he asked me to fill in a form. He assured that it was all I had to do.
“You will get the cylinders at your railway station after a month. Whenever the railway station informs you of their arrival, take a bank pay order; submit it to the railway parcel office and you can take away the cylinders.”
Amazed I asked, “Is that it?”
“Yes” was the reply.
“Nothing even to pay right now?”
“Nothing.”
I got up and was utterly in shock. I simply did not believe in him, so I borrowed an oxygen cylinder from one of my friends and I forgot the whole matter.
Sometime later, I was surprisingly contacted by the Kinwat railway parcel office about the arrival of my cylinders. I gave the pay order. I took the cylinders and came back to the hospital. It was one of the examples how India is run by the few honest ones. It was a sheer miracle, showing a few systems do work with all honesty and integrity in every field.
So our hospital began, but I avoided major surgery like Caesarian sections at all cost. Whatever was possible to avoid the Caesarian section, I did. No one will ever really know what it means to practice major surgery in a village setting. This is an ultimate question of one’s own conscience. If a woman is serious enough not to afford a timely journey to the nearest town, the fate rests in my hands. In bigger towns, the situation is quite different, where there are facilities like blood transfusions, colleagues available to help when in need, and you always have mental relaxation with this assurance.
I was successful in Kinwat because I worked at Hemalkasa, under Dr Prakash Amte. I have therefore previously operated in candle light and had training in difficult settings. Otherwise the standard medical education in Bombay does not equip you to practice in villages. In a village the very awareness that you are alone makes major surgery a sheer stressful thing. I was always terrorized by the thought that I was alone in the radius of 150km radius. My responsibility wastherefore hundred times multiplied and I had to take difficult decisions.
I wanted to avoid major surgery, especially whilst in private practice. Whenever a single failure hits you in a village, you can get destroyed. In cities, the patients are well informed about the risks involved including the possibility of death.
In a city, news does not spread like a lightening. In Kinwat, operative practice is always a risky proposition. To cheat is easy but to practice honestly and with transparency is always a problem. Adhering to logic is very difficult when patients are irrational. So I was defensive. I operated in major surgical cases only when the patient was dying. Otherwise in planned cases, I was conservative.
All my admissions were serious cases. Sometimes I admitted meningitis, or obstructed cases, maybe a very seriously dehydrated child. I also had a big problem of assistants in the operation theater. My assistant, Ganpat was illiterate. I trained him, but my difficulty was how to train? Without actually assisting the operations how he would get training? So I conducted mock surgeries. It was a funny situation indeed. We were operating on ghost patients!
There was one trained nurse who had retired a long time ago because she had married a landlord in Kinwat. She was from Bombay. I pleaded with her to assist me in major surgeries. She consented. Her name was Meenaxi. She always came whenever called. Without her love and support, Jyoti would never have lived in Kinwat. Meenaxi was a lecturer in alocal college. She was the first; Jyoti was the second woman in the town who drove a bike.
Before I settled in Kinwat, the obstructed labor case meant danger of death. Very few reached successfully to the government hospitals 150km away.
Janabai came – As an obstructed labor case. She was in labor for more than forty eight hours in her village 20km away. The government doctor had admitted her for one more day but without any help. The government hospital was not equipped for major surgery and the government vehicle was standing idle due lack of funds to repair it. So she could not be transported free of charge to the town and she had no money. She was just eighteen years old.
So after three days of obstructed labor she came to me. She had one hundred and three degree temperature. She had just five grams of hemoglobin (normal range starts with twelve).
She was in agony. She had to undergo caesarian, it was a race with death. I prepared all of her relatives for possible death in operation. I gave a long sermon, as if I was giving a lecture to post graduate students. I warned about all possible dangers. Jyoti prayed to her Goddess. I was atheist.
I remembered all the steps. I ran it in my mind. Like a film. Jyoti anesthetized her. Meenaxi was assisting in the operation theater after a gap of twenty years. The patient’s general condition was deteriorating. I was hurriedly going in my steps, as fast as I could. I removed the baby and handed over it to Ganpat. It was alive. A miracle!
Jyoti moved with panic. Blood pressure was falling. Jyoti sat on the stool with loss of nerves. Meenaxi had forgotten her spectacles, so she was taking time to thread the needle. Death was near. By reflex Jyoti got up and went to the gasping child. I shouted and reminded her to leave the baby and concentrate on the patient. She turned. I was calm. I sutured her back. I was sure that I was suturing a cadaver. I did not even look to Jyoti, but Jyoti did wonder. The BP shot back. The patient came out of spinal. She moved.
I asked Ganpat to hold her legs. We never had the guts to re-anesthetize her with general anesthesia in her poor health. I finished suturing the skin. Threw the gloves. I was perspiring. Dizzy.
The patient was incomprehensibly speaking. Like the mother in law, the goat. The hut. And many unintelligble things. I inquired with Jyoti. She had no clues except fear that her brain must have been damaged due to low BP. But she was puzzled.
“Her BP was never below seventy. I had given jolly good oxygen!”, she exclaimed. “This is not a brain anoxia.”
She was not sure, “May be low hemoglobin is the culprit”, she concluded.
I came out. The very fact that Janabai was alive was a cause enough for the joy out side. All were jubilant except me and Jyoti. I gave another lecture. I let them understand about the seriousness of the patient. We just could not expand the cause for her irrelevant talk. So what could we give her to cure her? It was three at night.
The IV line was on. She was in the operating room. I had no post-op recovery place. Suddenly I heard a cry from the baby on the table. We ran to it. We had all forgotten it. Jyoti lied down on the delivery table in the adjacent room. She was exhausted. She joined me after some time. We sat on the steps outside the hospital facing the road and the sky. She held my hand. The woman was to die, it was my first major and is as going to be failure. The word would be spreading around fast. The hospital would be going to get shut. No doubt.
So after conceding total defeat and after having lost all hope, I completely calmed down. I began thinking rationally. Why I was presuming that condition of the patient was related to
operative procedure? Was there any other cause? What could it be? What could evoke irrelevant brain response? Alcohol?
I sprang. I ran to the relatives who were sitting away in a corner of my hospital compound.
“Was Janabai an addict? Alcohol?”
“Tobacco” came the reply.
“She needed at least five packs every day!”
I came and hugged Jyoti!
“This is a bloody nicotine withdrawal syndrome! She is deprived of her daily dose for the last three days. It was all obvious. I inserted some tobacco in her mouth under the tongue. She quieted. She slept. We had won. At four thirty, we returned home. We slept in a hug. We could not sleep; neither could we speak a word, nor was the need.
We slept just as we were because we were there, Janabai had lived. The baby had lived. Between death and Janabai was our Biradari Hospital. It was the first ever operation in an entire 150km radius. The rays of a hard earned achievement of man in the form of science and technology had reached Kinwat for the first time because of our tiny efforts. The hospital had started functioning. The question was whether it would sustain itself financially?
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