|Sonam Norboo Memorial |
Governmenthospital, Leh, Ladakh
I am positively surprised at the cleanliness and the good working climate.
After some bureaucratic hurdlesI received permission to work in the SNM hospital. Because it was taking too long for me to receive my permission, a few days before I had already set my foot in the hospital. Dr. Tashi Mortup, the surgeon did not have anything against it, probably however the Medical superdirector, who was very distrurbed due to the current Medical Super Specialist Camp (see below) and his shortly approaching retirement. I was even threatend with the police, should I attend the heart surgeries again without permission. Fortunately I could present the finally permission to him in the afternoon. Then everything was back in good order.
I am extremely impressed by the cleanliness and the good working climate amongst the physicians and sisters. Above all, if I compare it with the circumstances in Darjeeling five years ago and which will probably have hardly improved.
I joined Dr. Tashi Mortup Kayser's work, the only general surgeon.
OPD - Out Patients department (outpatient clinic)
The work week has six days, on which all have OPD from 10 am to 4 pm. 30 to 60 patients are seen daily. Many of the "Minor Cases" are seen by a surgon assistent. The diagnoses cover the whole spectrum of general surgery, many humps and bumps (seborrhoeid cycts, abscesses, lipomas, pathological lymph nodes), right through to tumours of the esophagus.
Smaller procedures are done in the Minor OT daily with unsatisfactory equipment.
The most important investigations, like a simple laboratory, ultrasound and X-ray are readily available. For these investigations the patient pays 50 Rupies (1 euro), to be seen by a physician in the outpatient clinic costs 1 Rupie (2 euro-cent). The in-hospital treatment, operations and necessary medicines are free.
Unfortunately few patients speak English and my Ladakhi and Hindi has not prospered far yet. The English of the nurses usually is rudimentarily too so, except with the physicians, communication is difficult.
OT - Operation Theatre
On Mondays and Thursdays it is OT day, on which we removed very many gall bladders (gall stones due to the high consumption of butter tea), surgery of hernias, larger wounds after traffic accidents and appendices. The two OT rooms are well equipped: "only one" table, a theatre light, electrical coagulation equipment, an electrical sucker and a good "basic" anaesthesia with halogen, nitrous oxide or intra-venous anaesthesia monitored by an ECG and puls oxymeter however without an electrical respirator. The equipment is sufficient for these procedures. Modern synthetic suture materials (manufactured by Ethicon in India) are available, but not always in the desired strengths. However, because of cost reasons traditional silk and cat intestine sutures are used in most procedures.
In the corner of the room there is an oscillating fan, contributing the necessary "fresh breeze". Frequently surgery is interrupted by power cuts for five to ten minutes until the generator gets started. That means, torch, no coagulation and no puls oxymeter.
Dr. Tashis Cholecystectomie via "mini Laparatomie" over a 2-3 cm long subcostal cut impressed me, and rarely took longer than 30 minutes.
I found the hygiene risky. The instruments are sterillised in an autoclave. However the table with the instruments is arranged only once in the morning. The theatre sister takes the necessary instruments during theatre. Hereby it already occurred once that she picked up an instrument with bloody gloves and then put it down again.
The instruments, which were used during theatre, are put in boiling water for five to ten minutes. But the boiling point at 3500m over the sea level is not going to be 100 degrees celcius. The electrical knife with cable, which is held together with scotch film, is placed in a bath with desinfectant but is rarely completely covered bythe liquid. Longer sutures left over are put into the bowl with iodine solution for the next patient, which is used for washing every patient.
I do not think that infections are frequent because of these "gaps" in hygiene. But it is not lege artis.
There is one surgical ward for women and one for men with each approx. 25 beds. A short round is conducted daily.
What I noticed (and was reported to me by tourists who were allowed to spend a night as a patient in hospital) is that the bed linen is not changed daily. Partialy there are blood stains. If necessary, patients are shifted from one bed into another, which might still be warm.
Super Specialist Camp
On my first working day I was totally surprised to burst into a Super Specialist Camp. In India rare, if not unique, the SNM hospital holds a Camp for one week in the year with many specialists from Delhi. The general surgeon, orthopedist, physician, gynecologist, pediatritian, ENT and ophtalmologisti, radiologist and anethetist based at the SNM hospital are supported by a heart thorax surgeon, child heart surgeon, oncologist, urologist, neurologist, pulmologist, cardiologist and a more.
Dr. Tashi translated for Professor Sampert, the heart surgeons, since he dose not speake any Ladakhi.
In Ladakh a very high number of patients have rheumatic heart disease according to Professor Sampert due to the bad hygiene and the insufficient antibiotic therapy of tonsillitis. Many congenital heart diseases are diagnosed very late. Many patients live very secluded in the mountains and have hardly no acces to medical aid. Thus complaints will not be trated early and few children have a medical examination on theire first day of school, if they go to school at all.
Prof. Sampert did a whole row of close mitral valvotomies and ligation of persisting Ductus Arteriosus Botali (insufficient conversion of the unborn blood system to the development of the lungs) under the simple conditions described above.
This Camp goes back on a Lama, who instead of meditating, is active. He is a politician and has begun 25 years back to financially support patients with heart diseases, so that they could be treated in Delhi. The number of the post operative care rose accordingly, so that 8 years ago Professor Sampert came to Leh for the first time. Three years back he had begun do"smaller" heart surgery. In the meantime a whole row of specialist accompany him. Nevertheless many patients must be refered to Delhi. Pure medical costs per patient treated in Delhi lie between 50,000 and 150,000 Rupies (1000 to 3000 euro), which are financed to the largest part by the commitment of Lamagi.
I am extremely impressed by the efficiency of the hospital, the commitment of the physicians and the administration as well as the devoted assistance of Lamagi for his people. And aparently everything without any foreign non government organisations!!!
The SNM hospital in Leh is probably obe of the best District Hospital in India. I think that there are many reasons, why that is the case. Ladakh is an Autonomous Hill State and strives for a certain independence. Thus pride and sincerity are a driving power. Also bakshish is rather unliked. Nearly all doctors are Ladakhis and so committed to their people.
For me this month was an eye opener to what a District Hospital in India is able of doing.
Elias, August 2005
Note for medical students and physicians
Leh in the summer months is a very touristic place. So people from the west are seen in the hospital not just as patients but also as physicians and students.
The language barrier is more difficult than in other regions in India where I worked, because the nurses here can not translate. Also the physicians have a strong slang, so I as an Englishmen had to ask a second time quite often.
The physicians here are helped most in the high season in summer by specialists, who can take some of the work load.
Who would like to work here should contact best in person or write to
Chief Medical Officer
Jamu & Kashmir
But you should expect quite some burocratic running arround, befor you can role up our sleevs.
Main Entrance of the SNM Hospital
In theatre by my frist heart surgery...
... and the first Close Mitral Valvotomy in Ladakh