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Working as a Surgeon in a Peripheral Hospital.

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I am a retired professor of surgery. After retirement I thought that I should go to periphery and serve the most neglected people of the country. Pakistan is an agricultural country where most of the population live in the rural area. But most of the good health care facilities, Government or private are situated in the big cities and towns. Our DHQ (District Headquarter) and THQ (Tehsil Headquarter) and private hospitals in the periphery do not touch the complicated cases and send them to the nearest tertiary care center. Where I am serving the nearest tertiary care facility is one hundred kilometers away.

I am working in a private welfare hospital in Rajana (District Toba Tek Singh) run by a foreign NGO, headed by Ch. M. Sarwar, Ex-Governor of Punjab. Local population of this area is a bit better off and slightly more educated than the other rural areas Pakistan. Rural society is closely knitted society. Everybody knows everybody. Almost every patient has some recommendation from some important person. Every government official especially from police and district administration is considered tobe a big officer (even of lower cadre) for them and they think that it is their right to interfere in every body's affair.

This healthcare facility known as Foundation Hospital Rajana is well designed, beautifully built, well equipped with a big a state of art clinical laboratory, X-ray and ultra sound department, well ventilated spacious wards. Well-equipped operation theatre private rooms, nursery, casualty, Surgical, medical, pediatric, ENT, and Gynaecology outdoors. The best service is of the maternity department which is run by three consultants and same number of woman medical officers. All departments including anesthesia are headed by well-trained specialist. There are 24. Nurses,8dispensers and four OT Assistants for 76 patients. It is besides other supporting staff. We do not admit emergency trauma surgical cases. We admit and operate, general surgery cold orthopedics and trauma. Urology (excluding endoscopic surgery and transplantation)

I am the only medical person in the surgical department. Though there are four medical officers but they only look after medical emergencies and medical cases. I deal with every type of surgical cases even some of them are hopeless. We do not take advance and very complicated and terminal cases especially which are refused by tertiary center. I try to explain them in detail the nature of cases and my limitations. Still they ask me do something for their patients. It reminds me of old Christian Missionary Hospitals which started in this sub-continent years ago which were run by priests and nuns. People expect the miracles. Any how I ask for a high risk consent which usually they are reluctant, perhaps they think that I am going to commit euthanasia.

Then they try to pressurize you from some important person of the area. Even after all this explanation if the patient dies after the operation there is so much hue and cry. The elders disappear perhaps for making some arrangements, the youngster produce an ugly scene, even they try to manhandle the staff and insult the surgeon. Some people sent threatening SMS eve nto burn the hospital. The well behaved ones expect to refund the hospital charges, even the money they have spent on medicine and entertainment of their guests. They also like to take the hospital ambulance free and also expect the Medical Superintendent and surgeon to be present at the funeral. Many times we have to call the police.

We are lucky that we have two nursing schools at Toba Tek Singh and at Gojra in this area so we are never short of the nursing staff. Retired Operation Theatre assistants, lab and X-ray technician from army are very good, are also easily available. So I rely more upon the OTAs and nursing staff for preoperative and postoperative care of the patients. I do not rely upon the medical officer for the following reasons:

1. There is always a shortage of the medical officer. Another reason is the overall shortage in the country. In addition Punjab government has started giving them so high attractive package that a welfare hospital cannot afford that. That is why we get part time doctors or China and Russian trained graduates, who are usually not so competent.

2. As mentioned earlier the Medical Officers expect that I will give them one or two operations to do on every list which is not possible in a private hospital for the sake of good reputation.

3. The other difficulty is to get a good anesthetist who are short even in the urban area. They always like to give spinal anesthesia which has bad reputation in general public. Usually they are afraid of pediatric anesthesia. Besides they demand a package which is given by the posh city hospitals but cannot be afforded in welfare hospitals.

4. Poverty is yet another problem. There are not many wealthy people in the rural areas in Pakistan and those who are rich they will go to big cities for treatment. No doubt our hospital is a welfare hospital but it is not totally free for all. It is a subsidized hospital. In view of the rising prices of everything including medicines chemicals. Equipment and high salaries of the staff especially of the consultant and medical staff, even this subsidized charges are too high for poor people. They are about one third of the local private hospitals and about one twentieth of posh hospitals of cities. Still the people prefer our hospital because of respect, good services and efficient care besides the good nursing care.

Blood transfusion service is a real problem in the peripheral hospitals. We ask relatives to arrange one or two bottles which usually they do. But suddenly if we need more then it becomes next to impossible. I remember once at Bahawalpur a patient was bleeding too much during operation, I sent my house surgeon a nice young girl to ask and convince the patient's relatives to arrange more blood. At once one old woman snapped that what a pink shining face you have why don't you give a bottle of blood for our patient (that young girl is now senior pediatric surgeon of Lahore. I don't know about the blood but she has lots of fats on her body. These villagers always start giving you such funny reasons instead of realizing the seriousness of the situation.

Some time you get in to a funny situation. For example last week it was very cold and windy with thick fog. So only three cases were admitted one day earlier(according to my routine) for the operation. I was happy that I will get free early and will do some reading and writing .Early that morning our Gynaecologist occupied the operation theatre along with anesthetist for emergency. L.S.C.S. for usual fatal distress. When my first case for gallbladder was lying down on the operation table and we were washed up then the anesthetist declared the patient has high blood pressure so anesthesia cannot be given. Mind it she had normal blood pressure in the ward before she came to the operation theatre. He tried different drugs but her systolic blood pressure shot up from 180 to 210. So the case was postponed and the next case was called who was an old man for stone bladder. He already had six operation in the past for prostate and bladder.

Every surgeon refused that operation so that was for me who had to do it. It was very difficult and time consuming operation, still it was done. I was waiting for the next patient when some. Chaudhary's (chiefs) flocked in the operation theatre office with a patient of skin grafting who should have come one day earlier. He had a full stomach. They were insisting that his operation should be done on the same day and they would not listen any reason. The next operation was of piles. When I came out after operation one of my dispensers came rushing with his uncle who had prostatectomy twelve days earlier and started hematuria. Immediate catheterization was done which is another long story. When I was waiting for the next case of skin grafting another Cesarean Section popped in with ruptured uterus and I had to wait again. Then came all my clerical staff with one VVIP (a Thanedar of this area) who wanted to get his twin babies circumcised. When I examined them both had hypospadias.

I explained the father about their deformity due to which it could not be done but he was not convinced and left with annoyance. So came my turn for the third operation.

I was late for my Zohar prayer and got scolding from my wife for being so late for my lunch. Don't worry it is my every days routine. Being the only doctor in Surgery department I am directly exposed to the insults if anything goes wrong. Still it is a great pleasure and satisfying for me to help these people and helpless community.

In the end I would like to make few suggestions for the guidance of those surgeons who wish to serve in the rural area:

1. Always be courteous to your patients specially the elderly ones. They might be anything at home but for you they are Sir, Madam, Baba and Bibi. Keep some distance from Mian Sahib, Chaudhry Sahib, Malik Sahib, Khan Sahib, Sardar Sahib etc. and don't allow them to be frank with you specially the chiefs of the community, otherwise they will be calling you to their residences for even minor ailments.

2. Keep friendly relations with local heads of the administration and police otherwise small officials will keep bothering you for minor things I don't find any harm giving them a courtesy call or throwing them a party off and on.Always keep in touch with local professional colleague smee Surgeon and Medical Superintendent of the local DHQ or THQ hospitals that is your union. Share knowledge and problems with them but never share with them your secrets. If you are in trouble call them for the help

3. Try not to take advance in highly complicated risky and terminal cases or where you expect too much bleeding like big thyroids or big malignant tumors. Do not operate hip spine and thoracic problems unless you have full equipment, facilities and good blood bank.

4. Always operate under good anesthesia with a proper machine and enough supply of drugs. Don't press the anesthetist for any anesthesia. Don't give anesthesia yourself even in the hopeless circumstances except local and Bier block

5. If you and the anesthetist are not happy about the general health or prognosis of the patient, take high risk consent. Discuss and explain to relatives of the patient about risk and problems.

6. For any abdominal catastrophe always arrange few bottles of blood. For intestinal perforation, obstruction, gangrene of intestine start to performproximal loop ileostomy. If patient's condition is not well, close the abdomen and refer to the nearest tertiary care center. For any thoracic surgical problem, put in tube in the chest under local and connect it to the underwater seal. For urinary retention due to any reason, you must be expert to put in a Foley's catheter or a supra pubic tube in the distended bladder under local anesthesia. You must be expert doing tracheostomy under local anesthesia in cases of upper respiratory obstruction due to any cause

7. Every surgeon comes across complications during and after surgery during his life time even in minor surgical procedures like circumcision. Important thing is to recognize it and treat it if you cannot, then refer himimmediately to the nearest tertiary center preferably accompanied by a trained paramedic or a doctor. Give them a detailed written information.

8. Try not to admit in the ward the advance and terminal cases until and unless the relatives know the seriousness of the condition and its hopeless prognosis. For them the best drug is opiates. I prefer tramadol by mouth with some antiulcer treatment.
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Publication:Pulse International
Geographic Code:9PAKI
Date:Jan 15, 2016
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