7. Rock n Roll on Mondays

Poonguzhali (right) coordinates the Operating Theatres.
Vimala (center) coordinates the surgical training.
Sivanthi (left) is one of the circulating sisters.

On Mondays, it’s common for most of the eight Operating Theaters at Aravind Pondicherry, to be dedicated to cataract surgeries, which can number as high as the hundreds in a given day.  From Tuesdays to Fridays, the Operating Theaters are scheduled for mostly “paying” cataract surgery patients, and patients requiring specialty surgery (ie. retina, glaucoma, pediatric, oculoplastic, refractive), though some free cataract surgery patients are also scheduled.  Except for retinal surgeons, Aravind ophthalmologists of all specialties participate in the Monday cataract surgeries.  With volume comes efficiency; with experience comes proficiency.  Never have I seen so many efficient and proficient eye surgeons under one roof.  “Poonguzhali” is the 24-year-old sister in charge of the Operating Theaters.  Every Sunday, she coordinates everything in the Operating Theatres: which cases are assigned to which surgeon, which team of sisters is assigned to which surgeon, which team is in which Operating Theatre, which cases are assigned to trainee doctors.  During my stay, an ophthalmologist from China came for one month of training in ECCE (Extra Capsular Cataract Extraction), therefore only the appropriate cases were selected for her.  Whereas I was assigned the moderate to brunescent to white cataract cases, other surgeons more experienced with hypermature cataracts were assigned the black cataract and the Morgagnian cataract cases.  What the West considers to be a mature cataract, for these surgeons, is merely a moderate cataract.  What the West considers to be challenging surgery, for them, the surgeries were tackled with relative ease.  Poonguzhali had to predetermine which patient is for which surgeon, based on each patient's cataract condition, to ensure a smooth flow.

The two surgical units of  "D" Operating Theatre.
Each unit has one scrubbed and two circulating sisters. 

High efficiency, high volume surgery, with two surgeons
in the same Operating Theatre, each surgeon commanding
two surgical units of sisters, each unit of sisters responsible
for each surgical table and the patient for that table.

A surgical unit consists of one operating microscope straddling two operating tables, with one scrubbed sister at each table, and one or two circulating sisters supporting the scrubbed sister.  The surgeon is the head of the surgical unit.  Each Operating Theatre has one or two surgical units.  The circulating sisters support the scrub sister, such as preparing sterile surgical instruments, fetching supplies or IOL, helping patients to or from the operating table.  Poonguzhali choreographs the surgery flow, thus if one surgical unit is slower than another, she would assign the backlog of patients to the faster surgical unit.  Anything that could slow a unit – whether it is an intraoperative complication, surgeon inexperience with certain steps of the surgery, inefficiency with the patient turnover – is logged and reviewed later without prejudice.  All patients on Monday are given lidocaine retrobulbar or peribulbar anesthetic block by a senior trainee, then escorted on foot or transported via stretcher to the hallway adjacent to the entrance to each Operating Theater.  While the surgeon is operating on one patient, the adjacent operating table is readied with the next patient, who receives topical iodine and periocular prep, draping, and 5-0 silk bridle suture performed by the scrub sister.  Once the surgeon completes one surgery, he or she then swings the microscope to the adjacent operating table, remain gowned and sterile, with chlorohexidine wash on the sterile gloves between the cases.  Likewise, each scrubbed sister stays on her respective table, remaining sterile with chlorohexidine wash on sterile gloves between the cases.  On the Monday free surgery days, all ophthalmoloigsts tackle the cataracts with the MSICS (Manual Small Incision sutureless Cataract Surgery) technique, less than 10 minutes from conjunctival incision to conjunctival cautery closure, and frequently within 5 minutes, per cataract surgery case.

Shared room for "free" patients

Shared room for "direct" patients

Cataract patients fall into three categories: free camp patients, direct patients, and paying patients.  "Free" camp patients are brought in by the Aravind Eye Hospital buses, live far away, and tend to have the worse pathology because they have little access to eye care.  They can receive free eye surgery.  "Direct" patients visit the Aravind Eye Hospital directly through their own transportation, and thus live closer to the hospital.  They pay 750 Indian Rupee to cover the cost of consumables for the cataract surgery, but receive the services of the surgeon and the hospital for free.  Any patient can chose to pay for surgery.  “Free” is a choice, and “paying” is also a choice.  Patients without the financial means have no choice but to choose free surgery, but even patients with financial means can chose to receive “free” surgery, by being a "direct" patient who pays the INR 750 to cover the consumables.  (As of this writing, INR 750 is USD $12.25.)  All cataract patients are admitted to the hospital prior to the surgery, to have all the necessary measurements.  Upon admission, they stay overnight.  “Free” patients sleep on the ground, in rooms designed to house 20 or more patients.  “Paying” patients have sleeping arrangements according to the amount paid.  "Direct" patients who paid the INR 750, sleep in cots in a shared room.  Patients could also choose to pay more for private rooms.  “Free” patients and "direct" patients all receive PMMA (polymethyl methacrylate) one-piece

spherical IOL for ECCE or MSICS technique

of cataract surgery.

Private room (with bed for relative) for "paying" patients

“Paying” patients pay more according to the type of IOL chosen, ranging from acrylic foldable one-piece hydrophilic spherical IOL, to acrylic foldable one-piece hydrophobic multifocal or toric IOL, and can choose MSICS or phacoemulsification technique for cataract surgery.  Sisters responsible for patient counselling use a fee scale matrix to explain to patients, what their options are.

Very few camp patients chose to pay, because paying for surgery is often beyond their financial means – in fact, for many camp patients, leaving their farm fields for hospital admission and eye surgery already incurs a financial cost for not working on the farm.

Paying patient rate chart

For that reason, camp patients do not even have to pay for the consumables of the cataract surgery.  "Direct" patients who come to the hospital, choose the “free” surgery - the ECCE or the MSICS techniques of cataract surgery - but pay only the INR 750 to cover materials used during surgery.  They could also choose to pay more, once the other paying choices have been presented.  The Aravind model does not discriminate.  “Paying” and “free” patient are treated with the same respect.  Through the Western eye, sleeping on the floor does not seem appropriate, but that is a choice the patient makes.  Sleeping on the floor is what the sisters do in their residence, and is culturally acceptable among the locals.  A “free” patient may be treated by a trainee ophthalmologist, a resident ophthalmologist, a fellow ophthalmologist, or a staff doctor including the chief medical officer.  A “free” patient does not request a particular surgeon, since they come for Aravind’s free service.  A “paying” patient may request a particular surgeon, but the fees paid go to Aravind and not to the surgeon, since the surgeon works for Aravind.  None of the surgeons are compensated according to the number of surgeries performed, but only by their duties and responsibilities, commensurate with their seniority.  An Aravind surgeon called upon to manage the surgical complication of another Aravind surgeon is not compensated financially.  The eye surgeons who work at Aravind know that, by choosing to be an Aravind surgeon, they are answering to the higher calling of being a part of the Aravind team.  This is the beauty of Aravind – all surgeons who chose to be a part of the team, take care of each other within the team, thus the competition is friendly, and mutually-respecting.

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