Doctor's Review: Medicine on the Move

August 16, 2017
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Stepping in

A Canadian neurosurgeon gets his feet wet training residents during the rainy season in Indonesia

It had been planned for over nine months. It was an irresistible chance to leave my sterile privileged world to teach and operate with those and for those less fortunate. It was a chance to do something special, but it was also a bit daunting.

I was heading to Bandung, Indonesia under the auspices of the Foundation for International Education in Neurological Surgery (FIENS), a neurosurgical version of Doctors Without Borders. The decision was triggered in part by my involvement with a philanthropic effort in Kolkata (Calcutta) in 2002. But mostly I had a heightened interest in global ethics and equity, after studying for two years for a Masters of Health Science in Bioethics alongside developing-world students.

There were other FIENS locations besides Bandung, but based on their large residency training program, I felt this was where I could make the greatest impact. Also, a friend from Vancouver who was active in FIENS had been to Bandung before and strongly urged me to go.

So I would be a North American Jew in the country with the largest Muslim population in the world (about 200 million!) where two terrible terrorist bombings had recently occurred. And it was the height of the rainy season.

On day zero, when my nervousness and anticipation were peaking, there were unpredicted hassles at Toronto airport about a visa. The Canadian Embassy in Jakarta, the Indonesia Desk at External Affairs in Ottawa, my Indonesian hosts and my travel agent had never mentioned one -- and they turned out to be right. Finally the airline check-in agents gave me permission to get on the flight at the last minute. I didn't even have time for a proper hug and kiss with my wife.

After a longer-than-usual 16-hour flight to Hong Kong because of strong headwinds, I missed my connection to Jakarta. The next flight was eight hours later and took seven hours because of a stop in Singapore. As I heard the landing gear engage on approach to Jakarta, I was full of too many emotions to keep track. The overwhelming feeling was of a little boy on his first day at a new school.

I got into Jakarta dead beat and nervous and I was deliriously thankful to be met by a trio of the host doctors holding up a sign which read "Dr Mark." We embarked on the final leg of my journey, a hair-raising drive in the black of night through narrow mountain roads packed with cars, buses and people. I arrived at my hotel at 3am local time, 44 hours after leaving my house.

SYNAPSES FIRING
The first week in Bandung was quiet work-wise as Ramadan (known as Idul Fitri in Indonesian) was winding down and there were extensive holidays. I toured several hospitals with a few residents and staff, seeing patients of the four staff neurosurgeons.

At one of the private hospitals we met a drowsy lady with her second subarachnoid hemorrhage from what appeared to be a complex anterior communicating artery aneurysm. This case kept us busy for the week -- trying to explain to the family that surgery was risky but ultimately her best chance, going over the imaging with the radiologist and debating what further studies we needed, meeting the anaesthetist and trying to find the aneurysm clips and other microsurgical equipment which were seldom used and were locked away in some cupboard at the public hospital.

The neurosurgeons in Bandung had almost no experience with aneurysm surgery and the staff and residents were all quite excited about this case since the "great white hope" from the West was here to help with it. I was excited too. Doing a tough case far from home with unfamiliar equipment and perhaps unreasonable expectations from family and hosts certainly got my adrenaline flowing.

It actually turned out to be a bit of a nightmare. I had no idea how poor the equipment was at the private hospital. They had one microscope with only one set of oculars and therefore operating capability for only one surgeon. I had never seen anything like the self-retaining brain retractor system; I believe it was made in India. And the standard of nursing care was very low.

It was a bit of an ethical dilemma, but I decided I would do it, and do it the way I would back home -- not on my own, but coaching the residents. My mission in Indonesia, perhaps even more so than in Toronto, was to teach and empower young neurosurgeons.

Two residents opened beautifully and I managed to walk one of them through most of the intracranial dissection and only scrubbed in at the end when he was stuck. He actually ruptured the aneurysm and there were some exciting minutes until we got it clipped but we used temporary clips on the feeding vessels and got the job done. The patient went on to make a fairly good recovery given her preoperative condition. After a quick dinner out with the residents and staff that evening, and seeing some consults at two other private hospitals, I got home around midnight feeling fatigued but exhilarated.

THE WARD AWAY FROM HOME
The residency program was located at the Hasan Sadikin Hospital, the main teaching hospital of Padjadjaran University. There was a lovely new building which housed a very respectable intensive-care unit, a spacious emergency ward and very decent operating theatres. The atmosphere was friendly and professional like back home but much warmer. The dress code reflected the casual nature of the people and, of course, the climate. Residents wore short-sleeved waist-length white lab jackets, slacks and short-sleeved shirts with no ties or jackets. On Friday, the men wore white pants and a necktie until 11am when the day ended early to allow Muslims to get to noon prayer. Saturday was a regular workday and then Sunday again a holiday.

In the operating room, one left one's footwear in the change room and operated barefoot or in small floppy sandals used communally, if any were available. Many residents and staff operated barefoot. Being a typical uptight North American worried about communicable diseases, I purchased my own rubber sandals which I took home each day wrapped in a plastic bag and washed. The residents warned me that if I left them in the doctors' change room they would walk.

The neurosurgical facilities were in another complex of buildings which were much older, connected by open-air walkways covered by leaky roofs. The wards were decrepit, made up of depressing multiple-bed rooms divided for women, men and paediatric cases. The worn dirty spots on the floor often scampered away on six legs. Family members were camped out everywhere. Each ward room had a door onto a long screened-in runway with bathrooms. This crowded, filthy corridor provided living quarters for the myriad family members who took shifts caring for each patient.

The Neurosurgical ICU was an eight-bed unit with two ventilators and was completely managed by the neurosurgery residents. Like in the OR, you had to remove your shoes before entering.

The first case the residents showed me was one I felt had been mismanaged. It was a trauma case, a young man in a motor-vehicle accident, with a small cerebellar clot and very small subdural hematoma over one cerebral hemisphere with minimal mass effect. His Glasgow Coma Score had been 13 out of 15. We certainly would have observed him back home and only operated if he worsened, as it looked like he would tolerate both clots well. But he had been taken to the operating room and both clots removed via two sizable operations. Nevertheless, it was postoperative day three, he was doing well, and I couldn't argue with success. Furthermore the level of trust for the nursing care was so low that I guess the doctors often felt early surgery was the safest approach.

I gently and repeatedly imparted the message that there is more than one way of achieving good results and that the one with the least morbidity should be used whenever possible. I found in general that the residents were preoccupied with dogmatic information which led them to be too aggressive. They seemed to believe in elevating every depressed skull fracture which was not open (that is, with no scalp laceration over it) and which produced minimal distortion of the covering of the brain and no neurological deficit, just because it was depressed by one table thick.

They also asked questions like "How long should the corticotomy be to get to an intra-axial tumour?" There is no answer, of course, as it varies for each case; asking this question demonstrates a lack of understanding of the bigger picture.

HAND IN GLOVE
There are three neurosurgery residency training programs in Indonesia. Residents are selected after passing a variety of "psychological fitness" tests and an interview, presenting reference letters and, most importantly, proving that they can financially support themselves, since residents are not paid by the hospital or government. About half the residents worked as family physicians or emergency physicians in the afternoon and evenings to support themselves and their families.

There was apparently no limit to the number of residents trained and the program had grown in recent years from about 10 to over 40. There are under 100 neurosurgeons in Indonesia for about 220,000,000 people and there is no way 40 residents could be trained based on one or less elective case a day.

The residents' day consisted of operating on trauma cases or elective cases but only one, or no case was done each day. Most residents were in the classroom doing journal club, anatomy review and the like; they were more like students than residents. Their work day ended ridiculously early at 2pm. Every day, four residents lived in the hospital on call and a fifth was available from home. They were allowed no vacation time other than government holidays, like Idul Fitri. Perhaps this balanced how light their regular workday was compared to North American residents.

I got to know most of them pretty well and found them to be bright, well-motivated and friendly. I noted a true gentility and especially a sense of camaraderie. Typically, during a good case, four would scrub in and rotate activities so everyone got to expose, dissect and to close dura. It was nice to watch this even though it often disrupted the momentum of an operation.

 

By and large the residents had decent hands and satisfactory basic skills but lacked certain book knowledge, technical skills and "pearls" which can only be taught by an experienced neurosurgeon. Furthermore, the majority of their experience was based on trauma cases. They had some experience with hydrocephalus and with tumour cases, less with spine, and essentially zero with vascular and stereotactic/functional. I repeatedly got the impression that the judgement component of their training was grossly lacking largely due to lack of decent cases to learn from.

The four university neurosurgeons did not attend routinely in the operating room for public cases and, just like back home, not all of the staff members were committed to teaching the residents; one was even quite demeaning and rude to them.

I saw my role to be one of mentorship. My main technique was to spend as much time with them as I could, engage them in conversation about the art and science of neurosurgery, and the culture of being a medical healer as well as a technician. I spent about half my teaching time in the operating room and about half in seminars and other teaching sessions with the residents. I was slated to do 10 hours of classroom teaching each week. I also spent time with the staff suggesting ways they could improve, like letting residents operate on their cases and tried to show this by example. I was invited by staff to give my thoughts about how the residency training could be improved at the end of my stay. I prepared hard the night before and gave a very candid talk complete with PowerPoint slides to make the points clear.

THE KING AND I
One weekend, one of the senior residents invited me to his father-in-law's country home. It was a three-hour drive, near a small town called Garut. As we drove out of the city we listened to dangdut, traditional Indonesian music. On the way we stopped at a swimming pool fed naturally by a hotspring. I was just getting over my first illness in Indonesia, a nasty flu-like affair with diarrhea, and was slowly on the mend. After an hour in that pool I literally felt cured.

We went next to a lovely and simple restaurant for a traditional meal and turned up at his father-in-law's place in the evening. It was a delightfully complex and intriguing array of four traditional bamboo structures in a lush area surrounded by koi ponds and gardens. Beyond the property, rice fields stretched right to the mountains kilometres away.

I met people from four generations of his family. In keeping with all my Indonesian experiences to date, the introduction to females was perfunctory or nonexistent; I always had to ask their names as none was ever given.

I was led to a room full of his father-in-law's friends, ranging in age from 20 to 70, all playing traditional Sundanese (West Javanese) instruments. We all sang and his father-in-law and I dressed up in gorgeous Sundanese clothes. He was an interesting man who trained as a lawyer but ended up working for a tea plantation and had retired four years earlier as a high-ranking member of the Indonesian tea business. He and I immediately connected and took to calling each other the King of Garut.

At about 5:30 the next morning, the resident, his father-in-law and I simultaneously converged in a room where one of the servants had laid out tea and chocolate sandwiches. We took a brisk walk through gorgeous rice fields surrounded by a bowl of mountains. Many poor farmers were already knee-deep in mud tending the rice fields and all smiled and engaged us in a brief conversation when we said hello. We walked a few kilometres to a village bubbling with preparations for a wedding later that day, then we took a raft ride across a river.

We returned to the cottage where we each took a very needed shower. I was shown a room with a traditional hole in the ceramic floor for a toilet and a large receptacle of ice-cold water fed by an underground well. I "flushed" the toilet with a plastic dipper as is done by billions of people daily, and then poured the ice-cold water over my body. After soaping and rinsing quickly, I felt amazingly refreshed. A gorgeous Indonesian breakfast awaited before we headed back into the horrible traffic to Bandung.

As I walked up to my room I marvelled at the different people and unique experiences there are in the world. I laughed at the nervousness I and others had felt about my coming to volunteer in Indonesia in the first place.

THE NEW GRIND
The first morning report was the Monday after the week-long Ramadan holiday and 61 cases were presented over about three hours. There was one case of hydrocephalus from tuberculous meningitis (an infant who went on to die) but the vast majority of cases were trauma cases. Almost every case started with the introduction in slightly broken English: "The 25-years-old man was riding motorcycle and not wearing helmet and he fell down with his head hit the road." I have never seen so many depressed skull fractures and epidural hematomas in my life. The one week's experience was quite literally what I would see at the Toronto Western Hospital in a year.

Many patients were transferred from towns an hour or two away which lacked neurosurgical services. Unlike our system back home, the patients just turned up at the teaching hospital without a phone call from a referring physician.

Some cases were memorable for their sadness. A 17-year-old girl fell off a motorcycle and was drowsy with a large skull fracture. A CT would likely have shown an epidural hematoma and lead to a lifesaving operation, as the prognosis with surgery is excellent. But her family couldn't afford the CT and six hours later the patient stopped breathing and attempts at resuscitation failed.

It was not uncommon for me to be pulled out of rounds by a staff and with a patient beside him in the hall. The neurosurgeon would present his case to me and flip up the CT or MRI as people milled about. I would usually render a quick opinion based on incomplete information. My neurosurgical hosts explained to the patient that I was an expert in this area, even if it wasn't one of my primary areas of expertise. I felt like a bit of a fake sometimes as realized that my word was gospel Ñ if I said operate, the patient would be operated; if I said conservative treatment, thus it would be. The ethical dilemmas of teaching and operating in the developing world are a whole other topic.

After the residents left, I usually hung around to see what was going on, checked emails on the staff's computer when it worked, and walked back to the hotel along a street bustling with shops, people and life. Sometimes I was invited out for dinner to a staff's or resident's home or to a restaurant, and other evenings I had a bowl of noodles, a beer and some nuts alone in my room. I listened to music, watched television and spent a lot of time at my computer, preparing slides for teaching, editing the residents' manuscripts and presentations (a service I offered and was eagerly taken up on) and downloading photos from my digital camera.

THE V.I.P. TREATMENT
One of the residents was asked by the chief neurosurgeon to retrieve some teaching materials from a private hospital outside of Jakarta. I decided to go with him for the adventure and we left on the 6:30am train the next day. The ride was spectacular: we passed lush tropical forest and countless square kilometres of rice farms, many laid out in the typical tiered style up and down a hillside. What a job to reap the harvest twice (or thrice) a year. But just outside both cities, there were frequent fields stacked with garbage and the tracks were lined with shanties whose roof boards literally scraped the passing train.

A driver then took us through the traffic-clogged streets to the Siloam Gleneagles Hospital. Funded by a wealthy donor, the hospital had two neurosurgeons, both graduates of the Bandung training program. The chief was a man named Eka who was in his mid-40s. They were developing cerebrovascular surgery, having done about 100 aneurysm repairs and other "good" neurosurgical cases. They were seen as competitors by Jakarta's neurosurgical community, but maintained strong ties with their Bandung mentors. In fact, each Bandung resident spends a month at Gleneagles assisting on cases they do not see a lot of back home and providing the in-house care of the patients.

In an idyllic setting outside of Jakarta, the hospital was gorgeous and obscenely opulent, like the most affluent private hospitals in the USA. Eka was a dynamic engaging man with a superb command of English and we clicked immediately like old friends. He picked my brain about how to become even more competitive and I suggested developing complex spine surgery which neither surgeon was expert at. Most wealthy Indonesians apparently head to Singapore for neurosurgery if their problem can wait.

After a tour of the place, we went to the operating room where he invited me to help on a tough spinal cord tumour in the neck of a young man. While I watched the resident and Eka's younger partner expose the neck, the nurses chatted with me and made me tea. After Eka and I scrubbed and made short work of the tumour (two experienced neurosugeons can make challenging jobs look easy when they work together), Eka announced that I would now receive the ritual massage given to surgeons after the job.

I thought he was kidding but a lovely nurse motioned to a stool and proceeded to give me a professional 20-minute massage of my back and shoulders while she inquisitively chatted me up. This behaviour is typical of the close bond between OR nurses and surgeons everywhere in the world. I left Eka to close with the resident and the driver took us back to the Jakarta train station. I got into the hotel in Bandung around midnight after a wonderful, power-packed day.

Looking back on my experience, I highly recommend it to every developed-world surgeon. The impact that I and my colleague from Vancouver made is huge. All it costs is some time away from your family and a bit of lost income, depending on the type of group practice you are in. These costs can be recouped, but the knowledge, experience and culture passed on to eager young people who can transmit their experience to hundreds of others, is priceless.

I continue to correspond with many of the residents and will try to arrange for some to come to Canada for fellowship training or to attend our twice-yearly weeklong microvascular course at the Toronto Western Hospital. When they come I will pick up the fee and they will stay in my home.

The experience of being embedded in another culture in a faraway country was precious. It serves a vivid reminder that across this planet, there is much more that binds us than divides us. Everyone I met, including strangers on the street, treated me with courtesy, kindness and usually a beaming smile. Most of the mothers or spouses of patients extended their hands to me in the enchanting four-handed clasp typical in Indonesia. If I smiled at a child, the mother would look at me and return the smile sweetly and without hesitation. There was no avoidance of gazes. The overall experience was life-affirming and life-changing for me and I am certainly a much richer person for having done this.

 

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