ARSICON 2017 Take Home Messages: The Spine Foundation

The Spine foundation at Bombay has top surgeons working in the big hospitals joining together to provide spine surgeries in rural and remote areas. They provide low-cost care to patients in rural areas and use the Robin Hood concept for using the money collected from the rich.

They have developed simple procedures that are possible in rural hospitals and also diagnostic methods not using expensive investigations like MRI. They train the local staff in giving Physiotherapy and follow-up care. They have been doing approximately 100 surgeries a year for the past 18 years.

CLINICAL ESTABLISHMENT ACT: MODIFICATIONS REQUESTED

  1. 140 Square feet area for Operating Room
  2. Boyles apparatus need not be mandatory
  3. Pantry and separate toilets for ladies are not essential
  4. Since doctors are available on call and since they own the establishment duty resident doctors are not necessary
  5. X-ray technicians and x-rays need not be mandatory
  6. Blood storage center and Unbanked Directed Blood Transfusion (UDBT) should be approved

HEMORRHOIDS IN RURAL AREAS

Barron’s Banding or ring ligation is a useful method that is possible under Local anesthesia and less expensive and a better option is to use a cut Foley’s catheter rather than the ready-made ring.

THE RURAL SURGEONS

While WHO recommends a doctor population ration of 1 to 700, India has overall 1 to 1,000 and much less in rural areas. There is a lack of infrastructure and clinical skills are important in rural areas. The Government has one Primary Health Center per 30,000 population but in many places, it takes over 2 hours to travel there.

The Community Health Centers [CHC] catering to a population of 100,000 should have a trained rural surgeon. Creation of towns with 100,000 population, better infrastructure and mobile services could offer the necessary solutions.

Public Private Partnerships and insurance could be a way forward.

SURGICAL TUBERCULOSIS

Tuberculosis could affect any organ and mimic many surgical conditions. Abdominal tuberculosis is not uncommon. Genital tuberculosis could be as high as 20% in surgically removed specimen. Python sign described by Dr. J.B. Sharma is a new sign for Pelvic tuberculosis.

Diagnostic laparoscopy has increased the diagnosis and could replace the other diagnostic modalities for abdominal tuberculosis. Newer medicines are available.

JESS

Joshi’s External Stabilization System is a low cost external fixator developed by one of the pioneers of rural surgery. It is useful for treating a variety of conditions at a very nominal cost.

BREAST CANCER

The number of deaths due to Breast cancer is increasing all over the world while the increase is about 4,000 a year in Western countries it is 17,000 a year in India. Of the 2.5 lakh Breast cancers diagnosed every year about 40,000 die of the disease every year. Early diagnosis and treatment is important.

LAXATIVE ABUSE

Laxative abuse could cause hypokalemia, hypocalcemia and hypomagnesemia. Patients have presented with carpo-pedal spasm and positive Chovestek’s sing.

THE NIHR - GHRG RESEARCH PROJECT

The project would work to meet the unmet needs in Global surgery in rural India and Sierra Leone.

LOCAL ANESTHESIA TECHNIQUE

Rural surgeons often use local anesthesia. To make them less painful the following could be tried in addition to the use of reassurance and distraction and use of topical anesthetist and sodium bi-carbonate to reduce the burning sensation.

MANAGING TRAUMA

Managing trauma is very important in rural areas. The firs things to do are the following:

Triaging of patients started during the World war and a simple one to use is the SMART one.

GASTRIC CANCER IN NAGALAND

Gastric cancer is one of the common causes of death in Nagaland and in women it equals that of deaths due to cervical cancer. It was found that one out of every five persons had local complications with chemotherapy [all chemotherapy] and hence care is necessary especially after 3 cycles.

LSCS RATES

The World Health Organization has accepted a rate of 20% now because the increase in treatment for infertility. In rural area near Gudalur it is still between 5 to 7%.

OSTEOMYELITIS

Removal of sequestrum is important and if necessary the use of external fixation and vacuum therapy facilitates the recovery. Antibiotics are necessary only with systemic sepsis.

APPENDICITIS IN RURAL AREAS

The Modified Alvarado scoring system could be used in rural areas. With a score of over 7, 90% have histologically proved appendicitis.

gnanaraj Dr. J. Gnanaraj MS, MCh [Urology], FICS, FARSI, FIAGES is a urologist and laparoscopic surgeon trained at CMC Vellore. He has been appointed as a Professor in the Electronics and Instrumentation Engineering Department of Karunya University and is the Director of Medical Services of the charitable organization SEESHA. He has a special interest in rural surgery and has trained many surgeons in remote rural areas while working in the mission hospitals in rural India. He has helped 21 rural hospitals start minimally invasive surgeries. He has more than 150 publications in national and international journals, most of which are related to modifications necessary for rural surgical practice. He received the Barker Memorial award from the Tropical Doctor for the work regarding surgical camps in rural areas. He is also the recipient of the Innovations award of Emmanuel Hospital Association for health insurance programs in remote areas and the Antia Finseth innovation award for Single incision Gas less laparoscopic surgeries. During the past year, he has been training surgeons in innovative gas less single incision laparoscopic surgeries.
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