1

`Medical Elective – India

(01st February – 20th

March, 2011)

Figure1. Neuro O.T – Experiencing the unique opportunity of observing a live Cranioto-

my, through the Carl Zeiss OPMI Pentero microscope.

Medica Superspecialty Hospital−“Neuroradiology and Neurosurgery”

- By Harsh Sethia

medminus9@gmail.com

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Index:

Introduction-----------------------------------------------------------------------Page 3& 4

The Elective-----------------------------------------------------------------------Page 5& 6

Missing help!----------------------------------------------------------------------Page 6

Learning experiences-------------------------------------------------------------Page7

String of moments-----------------------------------------------------------------Page 8

Future learning---------------------------------------------------------------------Page 8

Appendix I---------------Elective approval letter---------------------------------Page 8

Appendix II--------------Elective learning objectives-----------------------------Page 8& 9

Appendix III-------------Time table------------------------------------------------Page 9

Appendix IV-------------Observed surgical procedures--------------------------Page 9& 10

Appendix V--------------Commonly used abbreviations--------------------------Page 10& 11

Appendix VI-------------Seminars, Workshops and Conferences----------------Page 11

References----------------------------------------------------------------------------Page 11& 12

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Introduction

Somewhere along the way,

You may lose something you thought was important.

But everything you need to fulfill yourself,

Is inside you or right in front of your eyes.

You just have to reach.

It often may not be easy,

But it will always be a great adventure.

~Anonymous

I was fortunate to be accepted for an elective attachment at Medica Superspecialty Hospital, India,

attached for 7 weeks to the department of Neuroradiology and Neurosurgery.

Fig2. Medica Superspecialty Hospital, Kolkata (India)

Medica Superspecialty Hospital is a tertiary care hospital with 500 beds, established in the city of

Kolkata. It was the first green hospital in the Country and serves as a hub to the smaller hospitals es-

tablished by Medica Synergie Pvt. Ltd. in Asansol, Siliguri, and various other North-Eastern parts of

India. The Department for Neurological Diseases (MIND) at Medica, is considered one among the

premiere Neuroscience Departments in the Country. Built by the dedicated efforts of many stalwarts,

the department draws patients from different corners of India and Abroad.

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Fig3. Faculty of Neurosurgery, Neurology and Interventional Neuroradiology departments after a Friday meeting.

The highly specialized faculty at MIND embodies the following sub departments:

Neurosurgery:

Dr. L.N. Tripathy (Director and Vice-Chairman at Medica)

Dr. Sunandan Basu (Elective Supervisor)

Dr. Harsh Jain

Dr. Kaushik Sil

Neurology:

Dr. Amlan Mandal

Dr. Ashish Das

Neuroanesthesiology:

Dr. Kallol Deb

Dr. Ratul Bose

Dr. Rakhi Mittal

Interventional Neuroradiology:

Dr. Aditi Chandra Sen (Elective Supervisor)

Dr. Ejaz Ahmad Bari

Dr. Arif Faizan

Neuropathology:

Dr. Sudipta Roy

Dr. Vinay Shankar

Co-ordiantor: Karabi Ghosh

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The Elective

The Elective attachment seemed like a much effective way to explore and discover my interests. Pre-

vious experience from my attachment at NUS, Singapore, as an Undergraduate Research Assistant

helped me appreciate how I could productively accomplish this Hospital attachment to gain a better

sense of the direction of my future research interests.

For the most part my role was that of an observer, as it would have been unethical on the Hospital’s

part to allow a 3rd year student to carry out medical procedures. In the MRI/CT Core Laboratory I

was allowed to navigate through the different medical scans of patients to develop and improve skills

of Diagnostic decision making.

During the ward rounds my supervisors, Dr Sunandan Basu, Dr Kaushik Sil and Dr Harsh Jain used

to explain, each case to me. Adopting the American style of learning, I use to do a follow-up reading

on the cases for the consecutive days. This used to help me, in understanding the Management and

Treatment approaches being adopted by the Sr. Doctors and also used to help me during the process

of gathering Clinical history and Physical examination of the patient.

Fig4. From left to right: CUSA Excel Ultrasonic Aspirator, Aestiva 5 Anesthesia Machine, Brainlab Kolibri naviga-tion system, Carl Zeiss OPMI Pentero Neurosurgical Microscope.

In the Operation Theater, being a novice I learnt about the various instruments, like the OPMI Pente-

ro Neurosurgical Microscope, CUSA Excel Ultrasonic Surgical Aspirator, Bipolar Coagulator to

name a few. During the pre-incision term, Sr. Neuroanesthesiologist Dr. Kallol Deb and Dr. Ratul

Bose used to demonstrate Tracheal intubation,1,2 Central venous catheterization3,4 and other minimal-

ly invasive procedures and taught me how to monitor the patient’s condition using Aestiva 5 Anes-

thesia machine, while carrying out these procedures. They also taught me some basics about the dif-

ferent Anesthetic agents, N-M blockers and Narcotics and their doses used.

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Fig5. (Left)Dr. Sunandan Basu during a surgery, (Right) Dr. Ratul Bose demonstrating central venous catheteriza-tion, with Dr. Kallol Deb and Dr. Rakhi Mittal in the rear.

During the O.T sessions the neurosurgeon also demonstrated the usage and application of Brainlab

image-guided surgery platforms, which allows them to wirelessly navigate during surgical proce-

dures. Several times prior to Surgery, the Neurosurgeon also took the initiative to discuss with me the

Clinical Neuroanatomy and the basics of Surgery, necessary to understand the surgical procedure that

to be carried out. At times, I was even fortunate enough to receive an entire demonstration of the

Surgery video clip by the Neurosurgeon himself or at times by the assistant Surgeon.

Every Friday morning, we used to have a Neuroradiology meeting, during which the entire MIND

Team used to discuss Radiological scans and images of all the important cases. These meetings used

to be among my favorite hours, especially due to two reasons. Firstly, there used to be so much food

for my brain. And secondly, the sumptuous breakfast and coffee served. The meetings used to be ad-

dressed by Dr. L.N. Tripathy himself and tracking his wisdom and experience through his opinions

and insights used to give a wonderful feeling, which I don’t have words to explain.

Missing help!

Although, Hospital attachment at Medica was a remarkable experience, yet I badly missed the

presence of other students. Being the only elective was a bit tough for the first few days, as at times,

boredom used to take the best of me. I also used to regret, not having the option of discussions and

collaborative learning.

There was also lack of e-learning facilities and library resources in the hospital, which I was able to

overcome with the help of Dr. Ejaz and Dr. Arif who suggested some very interesting websites offer-

ing useful e-resources. Dr. Aditi also contributed to the situation by lending her Scott’s Atlas.

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Learning experience

In course of my elective, I came across some really tough moments, which I was able to learn from

over time. On the second day of the elective, my Elective Supervisor asked me if I wanted to ex-

amine a patient. The difficulty here was that the patient was unconscious, and as a medical student I

was never trained to examine an unconscious patient. Having learnt examining an unconscious pa-

tient, that day was a memorable experience.

In the following days, I was allotted the job of collecting patients’ history, subsequent to the ward

rounds. In spite of having knowledge of Hindi, English and Bengali, I still faced problems in collect-

ing patient’s history and in demonstrating the first few cases to my elective supervisor and had to re-

visit the patient, at times in order to collect some missing details. I guess that’s how my supervisor

wanted to train me, for perfection.

Fig6. CT Scan room: (Left to Right) Dr. Ejaz, Harsh Sethia(me), Dr. Arif(in blue) and other staff members.

Another difficulty I faced during the course of the Hospital attachment was in understanding the vast

number of abbreviations used by the Doctors and other staff members in their conversations and lite-

rature. A small list of abbreviations regularly used by Doctors, have been listed in Appendix V.

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Stirring moments

Although during the course of elective, there were several miraculous moments, where we were as-

tonished by looking at the surprising recovery of the patient, there were some cases where the prog-

nosis itself wasn’t that good, and there wasn’t much we could do to help the patient, other than man-

agement and pain alleviation. But, the most disconsolate moment during the entire attachment was

when a 7yr old girl was confirmed with the diagnosis of Medulloblastoma.5,6 The 7yr old was a

small, cute and playful girl, who was enjoying her stay, even at the Hospital by capering around. She

was even curious to see her MRI results after having gone through the scanner, to have a glimpse of

how beautiful she was looking, as the nurse mentioned to her, that she would be taking pictures of

her (in order to keep her still within the scanner).

These are the moments when even Doctors feel helpless; as yet, they haven’t been equipped with

such resources that they can completely cure these little angels for a much better life, and many more

smiles, which they deserved.

Future learning

This elective gave me a more holistic view of Neurosurgeries, as I saw the patients from pre-

operative assessment right through to the recovery room. It also helped me gain comprehensive

knowledge of MRI and CT scan, as I went through the scans of hundreds of patients and tried to un-

derstand and learn the process of diagnostic decision making.

Based on my achievements and lessons gained from this attachment, I decided future learning objec-

tives for myself. As I couldn’t gain knowledge on fMRI from this attachment, I decided to look into

the literature for fMRI and to get hands-on information on fMRI through correspondence with Sr.

Neuro-radiologists at my home university. I also decided to utilize and improve my knowledge in

Neurosurgery by sharing my experiences with my university fellow mates, as having discussions

would help me gain a better understanding of the subject.

Appendix I: Elective approval letter

The link to the Elective approval letter is attached below. The Elective approval form was received

from Sudhanshu Roy, VP-Operations at Medica Superspecialty Hospital.

https://acrobat.com/#d=rpHUSaVmOjWnobmO1Uf6LA

*The PPE certificate obtained from the home university was submitted along with the application.

Appendix II: Elective learning objectives

History taking and Interview techniques.

Physical examination.

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Understanding and learning the application CT Scan and MRI in Diagnostic decision making.

Gaining skills of Clinical problem solving and Treatment approaches.

Seeking knowledge on various surgical procedures and techniques.

Appendix III: Time table

am/pm: Routine

9am Ward rounds

10:30am Operation Theatre

2:00/3:00pm MRI/CT Core Laboratory

5:30pm Ward rounds

*The time-table mentioned above was for Mondays-Fridays.

Appendix IV: Observed surgical procedures

Anterior cervical discectomy and fusion (ACDF).7

B/L drainage of subdural haematoma.8,9

Bone marrow aspiration for stem cell therapy.

Brainlab biopsy.10,11,12

Brainlab guided craniotomy and excision of cavernoma.13

Burr Hole Drainage.14

Cervical laminectomy and excision of tumor.

Craniotomy and aneurysm clipping.

Craniotomy and removal of meningioma.15

Craniotomy and removal of tumor.13,15

External ventricular drain (E.V.D): Right side.16,17

Extra-abdominal reposition and trans-abdominal fixation.

L4-L5 discectomy.

Laminectomy and screw fixation.

Lumbar decompression.

Lumbar-peritoneal (L.P) Shunt.18,19

Open Reduction, Internal Fixation (ORIF) of Frontal bone.20,21

Pedicular screw fixation.

Re-exploration and nerve repair of Right arm.

Revision of V.P Shunt.22,24

Stem cell insertion.

Thoractomy and removal of disc.

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Tracheostomy

V.P Shunt and Cranioplasty.

Ventriculoperitoneal (V.P) Shunt insertion.22-24

*Some procedures were observed numerous times, in different patients.

Appendix V: Commonly used abbreviations

ACDF: Anterior cervical discectomy and fusion

AD: Alzheimer’s Disease

ADA: Adenosine Deaminase

AF: Atrial Flutter

APTT: Activated partial thromboplastin time

ART: Anti-retroviral treatment

AT: Antithrombin

ATT/AKT: Anti-tubercular treatment

AVM: Arterio-Venous Malformation

B/L: Bilateral

BT: Bleeding time

C/S: Culture sensitivity

CAA: Cerebral Amyloid Angiopathy

CRP: C-reactive protein

CSDH: Chronic Subdural Hematoma

CSOM: Chronic suppurative otitis media

CT ratio: Cardio-thoracic ratio

CT: Clotting time

DAI: Diffused axonal injury

DC/DLC: Differential Lymphocyte Count

DLB: Dementia with Lewy bodies

DNS: Deviated nasal septum

ETV: Endoscopic Third Ventriculostomy

EVD: External ventricular drain

FBS: Fasting Blood Sugar

FLAIR: Fluid attenuated iversion recovery (A type of MRI)

GCS: Glasgow Coma Scale

HOB: Head of bed

ICH: Intracerebral Hemorrhage

ICP: Intracranial Pressure

LFT: Liver function test

MCI: Mild cognitive impairment

NCCT: Non-contrast CT-scan

NF+: Neurofibromatosis

NPH: Normal Pressure Hydrocephalus

OPLL: Ossified Posterior Longitudinal Ligament

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ORIF: Open Reduction and Internal Fixation

PD: Parkinson’s Disease

SAH: Subarachnoid Hemorrhage

SLR: Straight leg raising

SOL: Space occupied lesion

SOS: If needed/ If necessary

TBI: Traumatic Brain Injury

TC/TLC: Total Lymphocyte Count

TDS: Three times daily

TOF: Tetralogy of Fallot

Urine R/E: Urine routine examination

US: Unremarkable Strategy

WNL: Within normal limits

Appendix VI: Seminars, Workshops and Conferences

The Hospital attachment also brought me the benefit of attending some worthy events:

Workshop and Seminar on “Hand-washing and Advanced sterilization techniques.”

Conference on “Advanced treatments for gastrointestinal cancer.”

Seminar on “Poison control and management”

INFOCOM Conference and Exhibition, 2010-11.

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2. C. Michael Dunham, et al. Guidelines for emergency tracheal intubation immediately follow-

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http://www.east.org/tpg/intubation.pdf

3. Central Venous Catheterization.

http://www.surgicalcriticalcare.net/Guidelines/intravascular catheters 2009.pdf

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http://www.abta.org/sitefiles/sitePages/D3A2C571CD0CDE16C0FFE57607F22A65.pdf

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