Indian Journal of Surgery Medknow Publications on behalf of Association of Surgeons of India ISSN: 0972-2068 Vol. 65, Num. 1, 2003, pp. 102-103

Indian Journal of Surgery, Vol. 65, No. 1, Jan.-Feb. 2003, pp. 102-103

Challenges in Rural Surgery

A Dilemma of Rural Surgery

R. D. Prabhu

Shree Dutta Hospital, Tilaknagar, Shimoga-577 201
Address for correspondence: Dr. R. D. Prabhu, Shree Dutta Hospital, Tilaknagar, Shimoga-577 201

Paper received: June 2002
Paper accepted: September 2002

Code Number: is03021

The case highlights the difficulties faced by a rural surgeon in an otherwise simple case of carcinoma of the anus. The difficulties created a dilemma in the mind of the surgeon, should he help the patient, putting up with difficulties and expose the patient to increased risks ?

The difficult conditions under which a rural surgeon works put multiple social and economical responsibilities on his shoulders in addition to those of making difficult surgical decisions. He would be within his rights if he refuses to take them but his concern for the care of his patient, at times prompts him to accept them. If the patient recovers, everybody is happy; however if the outcome is unpleasant, more often than not, he is blamed for being overzealous, and uncaring.

In 1972, a year after I started my practice is Shimoga in a rented building, a 53 year old illiterate, poor widow came to me with a malignant ulcer in the anal canal. Biopsy had to be sent to Manipal, 150 km away and was reported as a carcinoma of the anus. In view of my constraints I advised the lady to go to a bigger place for further management. But she was totally against leaving Shimoga even if it meant a painful outcome of the disease. I had to explain to her and to her family about the difficulties and high risks of my undertaking the treatment, which at the time was abdomino-perineal resection of rectum and anal canal I believed that I could perform the surgery all by myself but everything else was heavily loaded against the procedure to be undertaken.

1. The only anaesthetist in town, a doctor in a government hospital, was a trained anesthetist but not qualified. My wife had been trained for three months in anaesthesiology. I had only an E.M.O. vaporizer as an anaesthetic machine and oxygen cylinders to supplement oxygen whenever necessary. Oxygen cylinders normally would take up to a month for refilling at Bangalore (275 km away) by the Indian Oxygen Co.
2. All our staff was trained by us. So every new procedure created its own problems.
3. There was not blood bank as such in Shimoga. The Government Hospital had a place where they cross matched the donor and collected the blood for immediate use.
4. My operation table was of the fixed height variety. I did not have the special stirrups needed for this surgery. I had only a pedestal operation lamp. The operation theatre was 10x15 ft in size.
5. Needless to say, I did not have an I.C.U. When needed, I had to be the monitor and take over the function of all the gadgets!

The patient and her family members agreed to accept all the risks, which made me anxious. I must also confess that I was rather happy for the opportunity to perform this procedure.

A local workshop owned by a resourceful engineer helped me fabricate a pair of stirrups that could give the exaggerated lithotomy position for the simultaneous abdominal and perineal dissections without changing the position in between. His stirrups were as good as those manufactured by commercial hospital furniture manufacturers except that they were not chrome plated nor of stainless steel. We organized for a unit of blood. Bowel was sterilized with Neomycin capsules and Sulphaguanidine.

The operation was performed on January 13, 1972 under endotracheal ether anaesthesia with E.M.O machine. Of course the procedure took some time but I could give her a good colostomy in the left side of the abdomen and could satisfactorily remove the anal canal, rectum and part of sigmoid colon.

Next day we felt that she will be better with one more unit of blood. I had to go to the Government Hospital myself to get this blood since the only male member of the family, her son was with the patient as demanded by the lady. But this unit created a problem. As soon as the blood was started, her B. P. fell down and we had to revive her with hydrocortisone, oxygen, noradrenaline drip, etc and maintain continuous monitoring during the night for the next ten hours or so! After that she recovered slowly and completely and went home on 1st of February, 1972. Colostomy was functioning well, she was walking about and eating well. But she was weak.

Our staff had no idea of how to care for a colostomy; so I had to teach the patient all that by myself, I enrolled her as a member of the Ostomy Association in Mumbai. But she could not read the literature nor understand the use of the bag and the belt, or how to give a colostomy washout. Later on I came to know that she could not afford the expenses of the membership and the low cost supplies the association gave her. She trained in the care of her colostomy in her own time and in her own way. She would cover the colostomy with a pad of old cloth and hold that in place with a roll of old sari around her waist. This worked well to her last days. She developed hypertension and cardiac problems in her old age and died of them in around 1994-95. She did not show any signs of recurrence or spread of the malignant disease to other parts of body.

I am happy that she decided to take the risks of surgery in Shimoga; she was cured of her cancer. But would the same decision be justified in the present days of consumer activism? Shri Shourie of Common Causes had expressed his opinion that the life of a poor patient is precious to his relatives; he has a right to expect the best treatment in a fully equipped hospital. But he would not say who was to bear the expenses. He said that as surgeons, we have to tell a patient to go to a better-equipped hospital if our own place is not so well-equipped. If we decide to perform any surgery in spite of the deficiencies, we have to take an informed consent:

1. in the language the patient understands, and with expressed knowledge that death is likely,
2. in the presence of at least one unrelated person and a social worker as witnesses.

This would apply to almost all the routine surgeries in a rural hospital; after all almost all the rural nursing homes have some deficiencies or shortcomings! I wonder how many would sign such a threatening consent. Many times it is impractical to find all those witnesses.

Should a rural surgeon struggle at all to save lives or to reduce morbidity in the present state of affairs in the rural hospitals and the aggressive tone of the consumer movement ?

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