Plunged in at the deep end

On the first morning of my elective, I turned up at the outpatient clinic expecting an introduction on how the hospital was run and what would be expected of me. Instead, I was simply told to “see patients.” I was at the Lady Willingdon hospital, a Christian charitable institution serving the people of Manali, a small town at the base of the Himalayas, and surrounding regions in northern India. It is run by a married couple, Laji and Sheila Varghese, who first came to the mission in 1979.

The workload is huge. Although it is a 35 bed hospital, extra space is often made for another 10 patients. About 150 patients are seen in outpatient clinics every day. The medical staff consists of three doctors, nine nurses (only one with official nursing qualifications), and 10 assistant nurses.

For the outpatient clinic I shared a small room with another doctor. The patients would have one or two relatives accompanying them. All but the most private examinations were carried out on a couch in the corner of the room. Rectal and vaginal examinations were performed behind a flimsy curtain.

One day each week was put aside for elective surgery. Emergency operations were carried out whenever necessary. Almost all the surgery I saw performed was under spinal anaesthesia. Without hi tech monitoring equipment, intubation and ventilation have a high complication rate and were therefore used only when absolutely necessary.

My first impression of theatre was that it was barbaric. A patient with a bowel obstruction had a laparotomy to investigate the cause of the obstruction. His wrists were tied down in the crucifix position: he was awake and apparently in some pain, although he was later given intravenous ketamine to make him more comfortable. Since no correctable cause was found for the obstruction, the bowel contents were brought outside his abdomen and evacuated by squeezing them towards the stomach and using nasogastric suction. However, most operations were not as dramatic as this one, and many patients appeared to be pain free.

A common theme that ran through my elective was a feeling of being useful, of helping rather than hindering, and that was certainly the case during surgery. Often, I doubled as both assistant and theatre nurse. To meet the many surgical demands, the surgical team had to work fast. As one patient was being stretchered out, the next was walking into the operating area. I saw Dr Laji complete a cholecystectomy in seven minutes, excluding closure time.

After being given a couple of days to settle in, I started doing on calls. I was expected to be on call once every two days, which was tiring, but ensured I became fully involved in the workings of the hospital. I lived in the hospital and, when I was needed, the night watchman or night nurse would bang on my door saying, “Doctor Kevin—patient, patient.” I soon gave up trying to explain to the staff that I was only a medical student.

My most satisfying case when on call was that of a man who had been involved in a car accident. His x ray film showed a dislocated and fractured elbow. I rang Dr Laji, who gave me some instructions on how to perform the reduction. After administering a sedative and painkillers, I enlisted the help of a passer by to apply opposing traction, and we attempted the reduction. The elbow seemed to crunch a lot, but appeared to be back in place, so we applied a posterior slab and plastered the arm, flexed at the elbow. During the procedure, we were plunged into darkness by the failure of the electricity supply (a regular occurrence), and I had to get someone to hold a torch. I then found the radial pulse, which returned to full strength after a worrying minute or two. A repeat x ray in the morning showed that the reduction had been successful.

Everything I had seen and experienced in my previous six weeks in Manali paled into insignificance after I had to attend a coach crash. The day had been much the same as any other in the clinic, when suddenly some cars came racing into the courtyard carrying injured people. About 20 of them had life threatening injuries—too many for us to cope with immediately. The man driving the first car said there had been a coach crash and somebody was needed at the scene where there were more injured people. I was told to go, so I picked up a stethoscope and was driven to the scene in the hospital jeep.

“Most people accepted disease and death as part of life”

When I arrived, I saw perhaps three or four hundred people standing on the top of the cliff staring down at a bus that was overturned and half submerged underwater. It had fallen off the bridge into the river. After pushing my way through the crowds, and being shown the safest way to get down the slope, I found a group of men standing on the chassis of the overturned bus, trying to get any survivors out. A few policemen were at the scene, but their organisational efforts and first aid skills were poor. Five bodies lay on the rocks. Nobody knew whether they were dead or alive. I checked each in turn and found no pulse or breath sounds. All had fixed, dilated pupils. They were dead. I was quite relieved by this, knowing that they would have lived only a short, agonising time because of their horrific injuries. After waiting some time to see if there was any possibility of more survivors being dragged out of the coach, I returned to the hospital, taking a man with a shattered humerus and a woman with a head wound. For the next few days, the hospital was bursting at the seams.

The morale of the staff, patients, and their relatives in the hospital seemed good, especially considering the amount of suffering present. Most people accepted disease and death as part of life. Patients were grateful for the care provided by the mission hospital and, in contrast with the expectation in the Western world that doctors should be able to cure all illnesses, they considered it a bonus when something could be done. My elective was at times enjoyable and satisfying, at other times frustrating, and sometimes heartbreakingly sad. There was so much to be done that even a fourth year medical student could feel useful and be of help. The hospital staff had my greatest admiration. They were thoroughly dedicated and doing the best they could with very limited facilities.