Rural Surgery
What is Rural Surgery?
Relevent Articles on Rural Surgery
2nd IFRS conference
ARSI Origin
ARSI Activities
ARSI Membership
ARSI Photo Gallery
ARSI Governing Body
ARSI Bullatins
Contact ARSI

  Presidental Address by Dr. Balu Sankaran at the second National conference of Rural Surgery at Shimoga, Karnataka on October 1st, 1994  
  Dr. Ranga Bashyam, Dr. M.S. Valiathan, Dr. N.H. Antia, Dr. R.D. Prabhu and colleagues who have organized this spectacular IInd A.R.S.I. conference at SHIMOGA, my dear friends, colleagues Ladies and Gentlemen.

It is a matter of pride and privilege to be the President of an active growing organization and I am thankful to both Dr. Rangabashyam and Dr. Valiathan for their inaugural address and key note speech. To say the least, I have been extremely inactive in the affairs of the R.S.I. since I was bogged down with other commitments, both in Delhi and outside India. I left Delhi to return to my home town sometime in February but I was summoned back by the 11th of April, to look into the emergency services of hospitals in the National Capital Territory of Delhi both public and private (of a bed strength of 150 or more). It was an education par excellence in the height and depths of hospital care in Delhi, and I thought I could share with you some of the thoughts that have emerged out of this study.

Delhi is a highly metropolitan city but it has in it the 2nd largest URBAN SLUM in the country though it is not concentrated like “Dharavi” of Bombay in one major area. It has a very large heterogeneous population from practically every corner of the country. It has the widest of roads and narrowest of lanes and areas of immaculate cleanliness and the largest of dumping heaps. It is estimated that there are 22 varieties of transport in Delhi with the craziest of drivers in the country which is benignly called the “Maruti culture” defined as overtaking and vehicle ahead of you on any side as well as from the top if possible. Its road accident figures naturally therefore is surpassed only by Mexico city and Lagos.

In the study I found the public hospitals of Delhi have to cater 26% of its resources to emergency department patients from outside metropolitan Delhi. They normally come from Uttar Pradesh, Rajasthan, Punjab, Madhya Pradesh, Jammu & Kashmir, Bihar and from anywhere else and the hospitals in Delhi spend about Rs.72 crore annually on these patients who attend only the emergency.

I requested all medical superintendents to answer a questionnaire submitted to them, which would give a birds eye view of the functioning of their emergency services. The speciality they tackle the number of minor and major surgical procedures carried out in the emergency theaters, the type of anaesthesia they use, the post-operative infection rate, the morbidity and mortality rate; the state of their blood banks and the testing of blood donors for various viral and bacteriological infections (Australia antigen; Non A + Non B; hepatitis B, HIV and VDRL) the fractionation of blood and blood products, availability of the intravenous fluids and their sterility the availability of disposable needles and prevention of their re-use, the techniques of sterilization adopted, the availability of instruments in the theatre, the investigations that are available (imaging, biochemical bacteriological and pathological including frozen sections). Questions were also asked about the kind and level of attention that a patient receives on entry to the casuality, whether any classification is done of emergency problem like a triage system (trauma score) Glasgow coma scale and the types of intervention that could be undertaken in the casuality itself. For example a laryngoscopy for removal of foreign bodies. The time taken for admission to I.C.U and I.C.C.U., the availability of monitoring devices in these two areas, the paediatric emergency care including neo-natal and the care of obstetrics and gynaecological emergencies. Neurosurgical emergencies, road traffic accidents with multiple trauma, were also looked into and paramedical training and training of nurses in handling of emergencies were also assessed.

The answers received from various institutions and my own personal impressions on the functioning of emergency services, were submitted as a report to the Lt. Governor on the 11th July 1994. It had a very good enthusiastic reception from the media in Delhi. What I learnt from this exercise was certain fundamental points which I believe are applicable to surgeons all over the country, wherever they might be located.

  1. Careful clinical examination and recording of findings preferably in a printed format is a must on all emergency care. No emergency is a minor one and this is the only way one could avoid mistakes.
  2. Basic investigations are a must and it might only be Hb, TLC, DLC, Urine examination to exclude diabetes or infection. Simple X-Ray of the chest or extremities involved.
  3. Careful transport of the patient with resuscitative measures when desirable or necessary (never by an open technique).
  4. Oxygen with a mask and I.V. line to maintain fluid in take when desirable.
  5. Arrest bleeding with the use of to urniquet or pressure where necessary.
  6. Cardio pulmonary resuscitation as and when required.
  7. An ambulance if available to be equipped with life saving equipment.
The patient on arrival at the hospital must be assessed by a doctor/para medical personnel well versed in the management of emergency. A quick recording of pulse, respiratory rate, blood pressure should be done and E.C.G. obtained if available and considered clinically desirable. A routine thorough clinical examination from head to toe for exclusion of depressed fracture of the skull, ocular and facial injuries papillary re-action, Glasgow Coma scale, injury to neck, thorax, position of apex beat respiratory excurision, percussion of chest to exclude hemo or pneumo thorax, pulse in upper extremity lower extremity and carotids, abdominal examination including the presence of fluid of blood. Examination of urinary bladder, genitor urinary examination and presence or absence of reflexes both sensory and motor and examination of all four extremeties for evidence of any damage or injury. Though this is primarily scheduled for examination of trauma victims it would point out other medical surgical, obstetrics and gynaecological problems that are likely to emerge in any casualty.

Classify patients that come into casualty after clinical examination into most serious and ordinary and always admit patients if there is any suspicion of progress in symptoms or signs on careful observations. If there is any other complication admit the patient (diabetes, blood pressure or previous history of cornonary infarction). With the consumer protection act becoming a reality, in most places the medical profession has lost its charm and is being classified as “a commercial enterprise”. And it would not be too long before all doctors face, mal-practice, charges, particularly since we as a nation do take after western attitudes. Therefore it is always desirable to have indepth analysis of your own establishment and have a critical review of your performance based on three criteria.

  1. Infection rate post operative or otherwise this-includes transfusion related problems.
  2. Morbidity rate as for example development of complications because or inspite of intervention.
  3. Mortality rate particularly within 24 hours after any intervention in the hospital (this should include cases which have been packed out of many hospitals just prior to death).
One of the major problems any surgeon is likely to face is an unacceptable infection rate. The permissible infection rate in closed interventions is 1% and in open injuries 6% according to the U.S.A. bureau of hospital standards (C.D.C. Atlanta data). In our public institutions the infection rate is as high as 25%.

It is therefore important to establish an infection control cell in any institution which renders inpatient and operative services. This should be preferably in charge of para medical or medical personnel not involved in the theatre managements. The infection control cell must have an independent bacteriological assessment (both aerobic and anaerobic organisms) of the theatre complex including the scrub rooms, the water supply the outlet pipes, the oxygen and suction machines, the air-conditioning equipments the lights the operating tables and any other equipment that might enter the theatre (such as a portable X-Ray unit). It would also be wise to have a monthly throat culture done of all individuals who enter the theatre complex. A sporadic and spontaneous culture of all hands of persons who take part directly in the operative procedure or those who handle equipment. This aspect of surgical care has not been given adequate emphasis, and should be a matter of priority for organizations like ours.

Another important avenue, that we should explore is the question of informed consent for a surgical procedure, either minor or major done with or without general/local anaesthesia. Informed consent is defined as explanation of the relevant surgical procedure as either emergency or elective, with reasons for the intervention, the complications that are likely to occur immediately within week or 10 days or long term. It should also include the explanation of the nature of anaesthesia to be used, the anaesthetic risks and the expected morbidity and mortality of the intervention.

These should be explained to the patient if he is conscious and to the relatives preferably the first descendant or the wife/husband. If the patient is illiterate, there must be 2 witnesses to the thumb impression. This document should also be signed by the surgeon as stating that he has explained to the patient and his relatives of the likely complications that are likely to arise as a result of the intervention. I believe the time has come A.R.S.I. must within the next one year standardize informed consent forms for the following 12 commonly performed surgical procedures.

  1. Laparotomy including appendectomy
  2. Hernia repair including strangulated hernias & hydrocele
  3. Haemorrhoidectomy
  4. Routine delivery and Fistula in Ano forceps application “C” section, Complications to both mother and child as for example asphyxia neonatorum
  5. D & C
  6. Tonsillectomy
  7. Supraputic Cystostomy
  8. Tracheostomy
  9. Suction drain in the chest
  10. Closed reduction of common fractures and complications of P.O.P application
  11. Upper G.I. tract bleeding and application of sengstaken tube or coagulation
  12. Nasal bleeding heomoptysis and its scare.
I believe these are common enough problems that should be looked into, and it is the function of our association to safe guard the patient as well as the surgeons.

I hope we act quickly and firmly and set a pace for other organization and Associations to follow.

Thank you for your patience.
Dr. Balu Sankaran