In January 2014, a surgical team from the Massachusetts Eye and Ear Infirmary, Boston comprised of American Academy of Otolaryngology – Head and Neck Surgery members Dr. Gregory Randolph, Dr. Paul Konowitz, Dr. Dipti Kamani and Dr. Dunia Abdul-Aziz, teamed up with ENT surgeons from across India at the Neeti clinic in Chikhaldara, India, a remote mountainous hospital in the outskirts of Nagpur. Surgical assistants included Madeline Randolph, a student at Providence College, and Jackson Randolph, a student recently graduated from Cornell University. Together, they embarked on an intense three day effort to not only care for patients with goiter and thyroid disease, but to educate junior Indian ENT surgeons on thyroid surgical technique, including neural monitoring, through hands on experience, interactive video surgical conferencing and formal lectures.
This effort marked the 13th annual thyroid surgical workshop, a surgical camp and educational tour de force sponsored by the Rotary Club of Nagpur South and inspired and led by Dr. Madan Kapre, a Rotarian and senior ENT surgeon in Nagpur. More than a decade ago, Dr. Kapre left his position as senior consultant in the UK, where he had received much of his surgical training, to return home in India. He sought to facilitate access to high quality medical and surgical care across India, including rural areas. In addition, he had a goal to mentor and educate junior ENTs in the art of thyroid surgery and the nuances of surgical decision-making. In this spirit, the Neeti clinic was created—combining his passion for service and education. Annual surgical camps were coordinated with the support of the rotatory club members. Senior surgeons from across India volunteered at the annual surgical camp to perform thyroidectomies and other surgeries. Simultaneously, as each surgery took place, an intense training session was carried out in an adjacent room as workshop attendants observed the case via streaming video.
By 2014, the clinic has evolved into a stand alone rural hospital, with two communal inpatient wards, a two table operating room equipped with general anesthesia capacity, a pharmacy, laboratory and full time medical physician and nursing support. The clinic manages the perioperative care—from pre-operative evaluation to post-surgical recovery—of all patients. Affiliation with nearby larger hospitals establishes a safety measure for patients who may require higher acuity care. In addition to the thyroid surgical camp, the hospital hosts general surgeons, orthopedic surgeons and ophthalmologist in similar camps addressing the medical needs of the Melghat tribal communities.
We arrived to the Neeti clinic in the evening of January 12, 2014 after an uphill journey from Nagpur to Chikhaldara. Pre-operative evaluation of each patient had already been completed by the onsite physicians and Dr. Kapre’s medical team, including his wife, an anesthesiologist, and his two daughters and their husbands who are otolaryngologists in India. Pre-operative ultrasound and FNA results had been obtained. Anesthesia risks, anemia, pregnancy and thyroid dysfunction were obtained prior to surgery. The patients were slotted for surgery over the next two days.
The start of surgery was marked by a team gathering outside of the operating theater with prayer to lord Ganesha for successful execution of the surgical camp without any obstacles. An excellent surgical team ensured the two-bed operating room ran smoothly. We worked side-by-side, and took turns with the other Indian ENT surgeons in performing the surgeries. The procedures were video conferenced to the hall upstairs where 40 ENT surgeons who had made the journey from across India and beyond (including a surgeon from UAE), were walked through the key teaching points of the procedure. Along the way, the salient aspects of management of thyroid disease were addressed both formally and informally through questions. What is the role of intraoperative nerve monitoring? How should one approach the parathyroid glands during thyroidectomy?
The surgical decision making–who to operate on and what surgery to perform—required tailoring to this particular clinical and geographic setting. Given the limited access to medical care, performing total thyroidectomies, which would commit patients to lifelong daily thyroid replacement and risk need for calcium supplementation was limited to special clinical circumstances (papillary thyroid carcinoma in a patient for whom access to medicine was ensured). For goiter disease, surgical planning entailed preservation of residual thyroid tissue to minimize the potential for hypothyroidism.
We introduced the intraoperative nerve monitoring (IONM) technology, pioneered at Mass Eye and Ear, and demonstrated its utility as an adjunct to anatomic identification and preservation of the nerve and as a tool for the initial nerve identification and tracing. We demonstrated the approach to troubleshooting intra-operative loss of signal. Equipment for monitoring was obtained through a grant from Medtronic and was brought from Boston to Nagpur. Nerve monitoring was easily assimilated into the workflow of the procedure and the skill was acquired by the workshop attendants.
In addition to the delegation from Mass Eye and Ear, senior surgeons and educators from across India took turns to operate and lead the workshop discussion, including: Dr. Madan Kapre, Dr. Alok Thakar from All India Institute of Medical Sciences (AIIMS), Delhi, Dr. Jyoti Dabhalkar from King Edwards Memorial (KEM) Hospital, Mumbai, Dr. Murad Lala from Hinduja Hospital, Mumbai, Dr. Ashish Verghese of Christian Medical College, Ludhiana, and Dr. Vikram Kekatpure from Mazumdar-Shaw Cancer Center, Bangalore. As cases were being performed in the operating room, attendants viewed the procedures in an adjacent room, stimulating active discussion about anatomic landmarks and the appropriate surgical maneuvers of each case. Through video conferencing, surgical knowledge, skills, and techniques could be disseminated across a wide spectrum of practicing surgeons in the communities from all over India. Beyond a surgical mission, this workshop was an educational one, hoping to empower clinicians with expertise in the challenges of thyroid disease.
At the completion of two operative days, the group travelled back to Nagpur for the annual thyroid Continuing Medical Education (CME) conference held in The Radisson, Nagpur. Building on the expertise of Dr. Randolph, the course had a special focus on the utility of intraopertative nerve monitoring, stimulating interest in the applicability and potential value of incorporating this new technology into general practice in India. At the conclusion of the workshop, 12 thyroidectomies had been successfully performed for indications of large multinodular goiter with compression symptoms and for papillary thyroid carcinoma. Beyond this, 40 attendants to the workshop left with a nuanced understanding of the surgical management of thyroid disease.
The philosophy of this mission is encompassed by the Chinese proverb: “Give a man a fish and you feed him for a day; teach a man to fish and you feed him for a lifetime.” Beyond the patients and families who were directly impacted by the procedures, there was an equally profound emphasis on surgical education from national and global leaders in the field. These younger surgeons, equipped with the new knowledge and expertise, are the vital link in bridging the medical gap that exists across rural and urban areas, in and outside of India. The surgical camp and conference thus serves as a ‘meeting of the minds’—as a vehicle for dissemination of information and surgical know-how—carried out in a concentrated setting. This arrangement can serve as a model for global surgical education—inspiring efforts to advance beyond medical missions in which foreign surgeons operate and depart.
In the end, our experience, operatively and beyond, was intensely moving and inspiring. A camaraderie among the entire participants of the mission was fast to form, growing from a shared commitment to excellence and safety. Out of one week grew a fellowship with the local Melghat community, ENT attendants and Rotarians that we hope will flourish with time.
Dunia Abdul-Aziz MD
Paul Konowitz MD
Madeline Randolph BS
Jackson Randolph BS
Dipti Kamani MD
Gregory Randolph MD.