My Experience at Tilganga Eye Centre:

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Written by Anya Gushchin

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A day in the life of an OPAL surgeon

I was fortunate to get a chance to return to Nepal as a Himalayan Cataract Project (HCP) International Ophthalmology fellow. My first experience at Tilganga was during medical school, and since then I couldn't wait to return to see the exciting changes and growth of this incredible teaching hospital. I spent 9 weeks working with Dr. Ben Limbu and Dr. Rohit Saiju, Tilganga's oculoplastic surgeons. Along with their fellows Dr. Puja Rajbhandari and Dr. Sulaxmi Katwal we made a cohesive, dynamic team. Some of the goals of my rotation were to become more efficient, hone teaching skills on an international level and operate as independently as possible in preparation for going to Africa. What I needed to learn about efficiency I learned from day one! In my mind, Tilganga is a model hospital for delivery of high volume, high quality eye care in this region as well as patients from all over Nepal, India, and even farther away. Their reach is even further due to the numerous outreach camps that are organized worldwide with HCP doctors and staff. Many visiting fellows come to Tilganga to take part of the many opportunities provided by HCP in order to streamline care for patients and learn the “tips and tricks” from the experts in maximizing impact in resource poor areas.

All students and visiting ophthalmologists usually stay at Nima's Guest House. If the rotation is longer, there are now apartments on site at the new Tilganga Centre. I was happy to return to my home away from home at the Guest House that is comfortable, close to the hospital, not to mention the chance to be part of a great family and meet many guests while having delicious breakfasts and dinners.  

Outpatient

A typical work week begins with two days of clinics. On an average day we would see 50+ patients in the morning. The clinics are on a first come-first served basis and patients are triaged to any of the slit lamps in our room by our nurses Charmila or Manisha. Depending on which room we were in, sometimes there were 4 slit lamps and I was fortunate enough to have a slit lamp to work with, otherwise I would float between stations and examine patients with our attending or fellow. My goal was to be useful, so I really enjoyed the opportunity to see patients on my own and develop a treatment and follow up plan for them.

After about 2 weeks I commanded enough Nepali to elicit a pleasant surprise on the patients faces when I asked them questions or counseled their instructions in their native language. After a few weeks, the level of difficulty increased as we started seeing a fair number of patients who spoke Newari (a very different regional dialect native to Kathmandu valley) and Hindi. It was great to have the nurses with us, because while transcribing our prescriptions for the patients, they were able to test the patients to make sure they understood my instructions. For example, it's critical after DCR (dacryocystorhinostomy surgery) that patients didn't put the nose drops in their eyes and vice versa. I got pretty good at making the patients realize the difference between the bottles, though.

At the conclusion of the morning clinic there was a break for lunch and the early afternoon we would see patients with follow up lab studies and review referrals (for instance ENT or radiology). It always amazed me the turn around times: patients would often return from radiology with their films or from the ENT consultant the same day so that we could make a prompt decision on the surgery they needed. After the afternoon clinic, the paid clinic began for the attendings and I got a chance to spend the afternoons working on my research project or join one of the attendings in the operating theatre for unusual cases.

Operating Theatre

Tuesday through Friday we spent in the operating theatre. Each day there was an assignment of cases to be done that day organized by level of difficulty/time. In the morning would be the general clinic cases and in the afternoon we had “paying” patients. As far as I could tell, the difference was the afternoon patients could afford to pay more of the cost of their surgeries, subsidizing the care for the patients who could not afford their treatments.  This is what makes Tilganga sustainable, and of course we would take care of them no matter what.

I really enjoyed the seamless way that the techs work in the OT at Tilganga. We had sisters who were scrub techs, circulators, and anesthesia techs who helped make everything run smoothly. I didn't have to go searching for instruments because our Instrument Sister would lay out all the instruments for the day on a back table, and if the cases had to switch in order, or be done in a different operating room, it was all easily available at our fingertips.

There are 8 OTs at Tilganga, and one of them is dedicated to patients who need general anesthesia – which we used quite a bit.  The remaining rooms are divided depending on how many retina, cornea and cataract cases are to be done that day. It was not unusual to have an OT list that is 40-50 patients long. Oculoplastics cases in general tend to be longer, so oftentimes if there were other smaller cases to be done and an operating theatre became available, we could utilize that room so that patients would not need to wait as long. I found myself wishing this was so easy in the US! 

The majority of our cases could be done under local anesthesia. All patients received intramuscular diclofenac and then local lidocaine anesthesia. I cringed the first time we went to perform a dacryocystorhinostomy under local, but it was not a problem. With a good regional block, the patients did not experience any more discomfort than at a dentists office (or equivalent).

I was very fortunate to participate in several cases that I didn't get to see or do in my fellowship last year, including several dermis fat grafts and a fascia lata sling. Both of these procedures require good knowledge of regional anatomy of the abdomen and thigh, something that is out of the scope of a typical ophthalmologist. With Dr. Rohit and Dr. Ben's guidance I now feel very comfortable with managing these types of cases.

We also had a series of challenging reconstructions and flaps in patients with trauma or oncologic causes of eyelid malpositions. The best part about our team approach is that we would all discuss the possible ways to repair and as a result discuss all the possible approaches. This is very useful for the fellows' training to come up with a plan and discuss pros and cons so that they learn the logic behind some of the reconstructions.

In general I scrubbed on all the cases and assisted the fellow through the cases. On several days when there was an open OR, all of us would grab a room and I would operate on my own. One important skill that is never taught in the US is how to be an effective solo surgeon. In training, we almost always have or are expected to have an assistant and, unless you are in private practice, you never get to figure out on your own some of the pearls for doing procedures easier. This type of experience is invaluable.

About a month into my rotation I prepared a morning lecture for the third year residents on eyelid malpositions. This was not only useful to gather and organize my photos to make a cohesive lecture, but also a topic that I've never had a prior lecture on. In creating a succinct powerpoint I learned a lot about what it takes to teach oculoplastics across cultures. For instance, my experience at Stanford was with a lot of Asian patients, but their eyelid anatomy is quite different than the mongoloid eyelids of several Nepali ethnic groups. As a result we had a great discussion on how the approaches might be similar or different when it comes to reconstructions. 

During my stay at Tilganga we hosted the 2nd National Oculoplastic Conference in Kathmandu: http://ocn2014.com/. It was well attended by local ophthalmologists as well as international guest speakers from India, US, UK, Australia, The Netherlands, Thailand and Israel. The two day conference was held downtown and was a great medium for sharing regional techniques in orbital, lacrimal and facial plastic surgery. In the evening, we put on an entertaining cultural program and also got to attend Dr. Suman Thapa's benefit concert right next to the conference center. Dr. Suman is a glaucoma specialist at Tilganga who is also a talented musician and plays in a rock band with the proceeds from his concernts going to subsidize treatments for glaucoma patients. Check out the Rusty Nails and this video that shows how well music and medicine go together: https://www.youtube.com/watch?v=3aV29XVaBQw. As a med student I had joined Dr. Suman on the first glaucoma outreach camp, so it was neat to come full circle and support his work now also. 

Overall

My time at Tilganga was an incredible opportunity. I would highly recommend coming to spend time with the teams there. The dedication of the physicians and staff at Tilganga is unmatched, and it was inspiring to get a chance to work side by side toward a common goal. During my time there we had a medical student and an undergraduate student who also came to clinics with us and I feel like the experience is worthwhile at each level of training. Each one of us was able to take away something to bring back home or in my case to apply when I go to Africa. I feel like Tilganga prepared me well for a career in International Ophthalmology and helped me make lasting friendships with like minded people.   

 

Anya Gushchin This email address is being protected from spambots. You need JavaScript enabled to view it.