Dr Edem Anyigba has recently returned to Korle Bu teaching hospital following an intensive year-long fellowship in Ganga Hospital, Coimbatore, under Prof Raja Sabapathy.Â Dr Anyigba was very highly praised by his hosts for his attitude and commitment, and his excellent report reflects on the immense value of the learning experience
REPORT ON ONE YEAR FELLOWSHIP AT THE GANGA HOSPITAL IN COIMBATORE, TAMIL NADU, INDIA
The purpose of the fellowship was Â to increase exposure to general plastic surgery principles and practice and in particular, to gain further exposure in hand surgery
The choice of Ganga Hospital was as a result of the difficulties in placement at the Canniesburn Plastic Surgery Unit and the favorable âword-of-mouthâ report of persons who had visited the unit.
Since the establishment of the Reconstructive Plastic Surgery and Burns Centre (RPSBC), Trainees have passed through the Canniesburn Plastic Surgery Unit of the Glasgow Royal Infirmary. Later developments have made this training option difficult and newer options were centers in South Africa and India. The Indian Fellowship in Ganga Hospital was to be a one year hands-on fellowship with emphasis on Hand Surgery.
The commencement of the fellowship coincided with the International Federation of Societies for Surgery of the Hand (IFSSH) Conference in New Delhi, India. Dr S Raja Sabapathy, made arrangements such the fellowship started with participation in the conference which was sponsored by the IFSSH for postgraduates
Report on the International Federation of Societies for Surgery of the Hand
The 12th triennial congress of the IFSSH and 9TH triennial congress of the International Federation of Societies for Hand Therapy (IFSHT) was hosted by India between the 4th and the 8th of March in Greater Noida, New Delhi, India. The Chairman, and host, who happened to be Dr Sabapathy, made arrangements for my colleague and I to participate in the conference, as well as sponsorship and accommodation for the two of us.
This was the first international conference I had attended and it turned out to be quite an eye opener, in particular, an introduction to outcomes of good organizational skills as demonstrated by Dr Sabapathy and his team of organizers. This was a trait I observed and hopefully have imbibed during the time I spent under his tutelage. Participation the conference also gave me the opportunity to meet and interact with some renowned surgeons in the field of hand surgery. We also benefitted from lectures and discussions with Dr Scot Kozin and Dr Scot Levine, who were guest lecturers at the Ganga Hospital in the days following the conference.
Working Experience in Ganga Hospital
My official date of commencement at the Ganga Hospital was the 11th of March 2013. However I had participated in the hospital activities and ward rounds over the weekend, together with Dr Opoku Ware Ampomah and Dr Kwame Darko.
During the first week I was able to complete registration with the Medical Council of India and registered as a foreign resident with the police, which were requirements for working and residing in the country for periods longer than 2 weeks. During the first week as well, I was also able to secure accommodation close to the hospital and moved from the hospital guesthouse and was now settled and ready to work.
The regular work schedule was in the form of morning and evening ward rounds, three times weekly outpatient clinics and daily theatre sessions from Mondays to Saturdays with Sunday usually reserved for ward rounds and was usually a half working day
Outpatient clinic experienceÂ
For a greater part of the year I was in Ganga hospital, outpatient clinics were held three times a week till January 2014 when the clinics were held daily from Mondays to Saturdays. The clinics were always well attended and there was a wide exposure to general plastic surgery cases as well as a plethora of hand cases ranging from fingertip injuries to complex brachial plexus injuries.
There were teaching sessions at the clinic and demonstration of clinical signs and examinations. The only limitation at the clinic was a language barrier when instruction were given to the patients in Tamil.
I also observed, and was impressed, with the doctor-patient interaction and the manner in which the patients were counseled and the surgical options, postoperative management, physiotherapy and follow-up plans explained to them. More importantly the patients were encouraged to ask questions which is not a common practice in my working experience in Ghana.
Another impressive feature was the promptness with which patients needing surgery and willing to have the procedure were admitted and prepared for theatre with no issues regarding waiting list.Â Patients admitted for surgery were promptly reviewed by the anesthetist and prepared for surgery the same day or the following day if it was considered a major case.
Operating theatre experience
The operating theatres were run on a daily basis. On non-OPD days, the theatre sessions started after ward rounds in the morning and were a combination of both elective and emergency cases as and when they presented.
The patients for elective surgery were prepared the evening before surgery, consent was taken and pre-operative instructions were conveyed to the ward nurses and explained to the patients as well. An electronic booking for surgery was also made for the patient, which is a simple and innovative method and excellent for record keeping, markedly reducing laborious paper work.
During the first month of my training, I had several opportunities to assist Dr Sabapathy as well as the other consultants in the hospital. The first case I had the opportunity of assisting was an Adult post-traumatic Global Brachial plexus palsy were we performed an exploration of the brachial plexus and neurotization of the biceps muscle with a sural nerve graft. I subsequently had the opportunity to assist more of such cases and several cases of brachial plexus injures who had free functioning muscle transfers for elbow and finger flexion.
Free flaps and local flaps were done almost on a daily basis and I had the opportunity to assist a large number of such cases.
Hand injuries and less frequently amputations also presented an opportunity to gain first-hand experience in the management of such cases from presentation and also subsequent secondary procedures carried out for such patients
I gained lot of operating experience during the on call duties which were averagely once weekly with an average of 10 patients presenting during the night and more during the day.
The theatres were well equipped and well stocked with consumables, which made working very stress free, and something to look forward to.
There was absolutely no hesitation to use the operating microscope when it was indicated and I thereby gained a lot of experience in both assisting and performing microsurgery cases.
I also gained a wealth of experience with maxillofacial surgery cases when I joined Dr Ravindra Bharathi during my last three months in Ganga hospital and at the completion of fellowship, I had participated in over 600 hundred surgeries.
Clinical experience on the wards
The wards also presented opportunities to interact with patients and also for teaching during the rounds with the consultants. Doctors generally carried out a number of wards duties, which included writing the case sheets of patients and documenting the daily progress of the patients. Wound dressings and care was also part of the doctorâs duties and I have gained a wealth of experience with wound care from simple wounds to large and complex wounds, including burn wounds, and it also gave the opportunity to detect problems in the early stage and promptly manage them.
Evening rounds, sometimes with Dr Sabapathy and the consultants, were valuable learning experiences and generally included both clinical and non-clinical tutorials. Dr Sabapathy shared important life lessons with Fellows during the ward rounds as well as practical clinical points and technical tips and always emphasized the correct methods of immobilization following surgery and little important detail on postoperative management of patients.
Ganga Hospital is accredited for post graduate training in plastic surgery, hand surgery, anesthesia and orthopedic surgery and also has numerous fellowships in all these disciplines hence, the institution has a good academic set up which was beneficial.
Academic teachings were held three times weekly with provisions made for visiting professors. Teaching was in the form of presentations by the residents, fellows and consultants on general plastic surgery topics, hand surgery topics as well as case presentations which were extensively discussed. I had the opportunity to present a few topics as well as cases.
There was also the monthly Coimbatore plastic surgeons meeting where plastic surgery cases and topics were presented and discussed and I attended all monthly meetings without fail and presented a paper at one such meeting on âa rare case of brachial plexus tumor with intrathecal extension in a patient with type one neurofibromatosisâ.
Visits by world renowned and eminent plastic surgeons to the hospital was a regular occurrence and Â I was privileged to meet and be taught by surgeons such Dr Scot Kozin, Dr Scot Levine, Prof Kanaya, Â DrÂ Igor GobulevÂ and Prof VenkatkhrishnanÂ who are all leading surgeons in their respective fields .
In April 2013, I participated in a one week microsurgery workshop organized by the Plastic Surgery Department of the Ganja Hospital and together with 2 other participants from England and India and together, we constituted the 500th, 501stÂ and 502ndÂ microsurgical trainees. The Centre has trained people from all over the world including other African countries and I was the first Ghanaian trainee at the Centre. Though this was the second microsurgical course I had undertaken (the first being the Canniesburn Microsurgery Course), participating in this course further improved my basic microsurgical skills. The training facility is well equipped with good supervision and attention to detail and coupled with the further real microsurgical practice, has greatly improved my skills in this regard.
Conferences and Workshops
I attended a number of workshops some of which were organized by the hospital these included:
- The Tamil Nadu Chamber of Commerce Conference on Medical Tourism. Chennai
- Ganga Operative Hand Surgery Workshop, Coimbatore
- Association of Plastic Surgeons of India Conference. (APSICON 2013) Mumbai
- Tamil Nadu and Pondicherry Association of Plastic Surgeons Conference (TANPAPS 20140) Tirupur.
These conferences and workshops enabled me gain insight into aspects of plastic surgery which are not commonly practiced in my Centre
During TANPAPS 2014 I presented a free paper on âthe management of primary tumors of the brachial plexus, a case series of 7 patientsâ. I am currently working on writing the same topic for publication.
Life outside the hospital
The regular hospital working hours were from 7:30 am to about 7pm from Mondays to Saturdays with Sundays usually being half days unless you were on emergency call.Â The other exception was post duty days off where the day ended around 10am following day from 7:30 am on the previous day. There was therefore not much time spent outside the hospital on a regular basis. However, a few friends a will usually organize dinner outings and I spent most of the Sunday afternoons in the multiplex of the Brookfieldâs Mall
Ganga hospital is an efficient set up and has a lot to offer both clinically and non-clinically. The prompt manner in which lab results, blood and other patient related matters are handled, is something I will like to see implemented in my center.
Radiological investigations and the PACS system made it simple and easy to refer to patientâs images as soon as they were taken
The anesthetist promptly saw patients and there were virtually no anesthetic challenges regarding availability
I witnessed several instances where poly trauma patients were promptly resuscitated and anaesthetized as part of the resuscitation and prompt surgical interventions made. I could only stand back and hope that one day such facilities and services will be available in my Hospital
Working Experience since returning
At the time of writing this report I had resumed work and just after 2 days I have notice a number of areas in which we can make changes that will have a great impact on patient care
Typed discharge summaries can be implemented at the cost of a computer, a printer and a typist and this will ensure that patients will have access to their medical records and will not need to carry bulky folders around. And we could also add to the discharge summaries clinical photographs
Recently, I was in the casualty department and saw a lady with a dorsal oblique amputation of the right middle finger tip, on further enquiry, I was told the plan was to wash the wound and allow it to granulate and heal.Â I sought consent and promptly debrided and covered the finger-tip with a V-Y flap. There is still the lack of awareness on the availability of hand surgery services and it is up to the Centre to make this known and our best advertisement will be to actively seek these cases and make the result of our surgical interventions known.
Subsequently, we can then look at popularizing microsurgical services and climb up the ladder of complexity.
For subsequent trainees who will be interested in other fields of plastic surgery, e.g head and neck reconstruction, aesthetic surgery, and breast reconstruction, there are several hospital in the same region where these are done and brief observer ships could be arranged for further exposure to these fields
A memorandum of understanding needs to be drafted and signed in the shortest possible time so that work done during this period will be credited to the trainee as part of the training with certification which will recognized by the Ghana College of Physicians and Surgeons as well as the West African College of Surgeons.
Further arrangements could be put in place to have interested anesthetists, maxillofacial surgeons and orthopedic surgeons also do fellowships or observerships and this will allow them to see firsthand the results of working together as a team.
I would like to thank the Chairman and Directors of ReSurge Africa, the management of Korle Bu Teaching Hospital and the RPSBC, the chairman of Ganga Hospitals Pvt limited and Dr S. Raja Sabapathy for the opportunity.
I will also like to thank Dr R. Bharathi, Dr H. Venkatramani, Dr K . Balaramani , Dr S. Ramkumar and Dr P. Bhardwaj who were my teachers and have done a really good job imparting clinical knowledge and skills to me.
I wish to extend my heartfelt appreciation to all the doctors and nurses I have worked with in the past year and I hope I made their lives easy as they made mine during my stay, to all these people I say âromba periya Nandriâ
Dr Edem K Anyigba