February 2017 | Issue 28
Sri Lanka surgery and trauma elective

IMG_6545c.jpgIMG_6567c.jpgBy Ang Wee Kiat and Tan Xuan Hao, Class of 2018

Situated near the southern end of Sri Lanka, Monaragala District General Hospital provides tertiary healthcare to patients from all over Uva province. We arrived on 19 December for a 14 day-long elective during our recent holiday.

On stepping into the hospital’s surgical unit, we were struck by the orderly rows of simple mattresses covered with a standard mosquito net amongst the hustle and bustle of busy nurses and doctors. As described by our mentor, Dr Kamal Jayasuriya, Consultant Surgeon, the hospital is “an austere environment that hones the clinical acumen of the doctor”. The fundamental skills – inspection, palpation, percussion and auscultation (the key pillars of a thorough physical examination), and clinical reasoning – play a crucial role in the assessment of patients.

Just moments after we arrived, a mass casualty trauma activation was called - a bus ploughed into another vehicle and seven people were rushed into the emergency room.

It was a hectic scene with only four medical doctors in a small emergency room, performing primary surveys and resuscitation. The nurses skilfully secured the necessary lifelines and catheterised the patients. Injuries and fractures were identified and immobilised as necessary. Everything happened swiftly. We did all we could to assist in our first ever mass casualty trauma activation. The elderly lady we followed through sustained multiple injuries, including bilateral thigh fractures. She was resuscitated with large amounts of supportive fluids (four pints of normal saline and two pints of blood). We were impressed by how the doctors coped and managed the mass casualty activation of seven trauma patients with the limited manpower and resources.

Sri Lanka - suturing.jpgSri Lanka - Xray.jpg
L-R: Providing some immediate care, Xuan Hao sutures a scalp laceration; the elderly lady we followed undergoes a chest x-ray

This is in stark contrast to the resources available in Singapore. Firstly, the lack of manpower was apparent. For each casualty, there was only one medical officer and three nurses. Secondly, there was no designated resuscitation room: the severely injured mass casualty patients were managed alongside the other patients of varying acuity status. Thirdly, crucial trauma adjuncts such as Focused Assessment with Sonography in Trauma (FAST) scans and other imaging scans were performed at the radiology department, which was a considerable distance away.

As we transferred our patient through the crowded hospital corridors, with pressure mounting with each alert from the monitors, we became truly appreciative of the manpower, resources and one-stop organisation of facilities in Singapore that support our trauma patients. However, the camaraderie and teamwork displayed by the staff to deliver the best of care while navigating the system has truly inspired us.

Sri Lanka - team.jpg
Taking a breather, we (Xuan Hao centre, Wee Kiat right) snap a memory with the ICU team who received our trauma patient

After receiving emergency care, Dr Kamal took over the care of these patients and formulated comprehensive management plans. While doing so, he made every effort to educate his team on the important aspects of patient management. He went through the priorities in each of the trauma patients, indications to repeat X-rays and FAST scans and he emphasised the importance of revisiting patients’ vital signs to monitor for possible deterioration.

Most notably, despite the stress and adrenaline rush, he never failed to comfort the patients with his succinct, yet powerful words of encouragement. As Dr Kamal later reiterated, “Doctors do not only treat physical body but more importantly, the mind.”

Each patient’s admission documents were painstakingly handwritten and kept in meticulously maintained folders; medications ordered and procedures performed were manually documented. In the clinics, the patients were given a hand-made cardboard token as their queue number. During consultation, the doctors reviewed the patient’s personal notebook for their medical records, prior consultations and interventions. Power failure during operations was not uncommon, but the doctors managed this challenge in their stride.

Sri Lanka - token.jpg
At the hospital, patient queues are managed using these number tokens

Learning in an environment less dependent on technology such as computers, we have come to appreciate the ease with which crucial patient information is retrieved in Singapore, which has helped to prevent medical errors to a certain extent. Yet, despite the tedious paperwork, the doctors synthesised information and with the aid of some memory tools such as small notebooks, truly “know the patients”, delivering the best care they can.

It is a reminder to never forget, in the face of increasing reliance on technology, the need to understand patients’ condition not as isolated laboratory results or diagnoses but as an integrated and holistic person.

This elective taught us more than just surgery and trauma, as we will always cherish the friendships made and the lessons in doctoring from our mentor, Dr Kamal.


Sri Lanka - with mentor.jpg
Exploring the beautiful countryside with Dr Kamal, our mentor

“A stable patient is a gift in trauma, we should manage actively and conscientiously as they can turn for the worse at any time” – Dr Kamal Jayasuriya, Consultant Surgeon, Monaragala