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Asha Vihar is a development aid project in the state of Jharkhand, Eastern India, that takes a holistic approach comprising conventional and alternative medicine to deliver free healthcare to those who need it most. Anaesthetists Dr Lukas Fischer and Dr Peter Lembach embarked on a voyage of discovery when they volunteered at Asha Vihar’s annual surgical camp for children with musculoskeletal abnormalities, seeing at first hand how surgery can not only reduce pain and disability, but also offer hope for a future free from social stigma. Dr. Fischer explains how postoperative pain management depended heavily on using point-of-care ultrasound (POCUS) to guide needle insertions and provide regional anaesthesia, enabling life-changing interventions.
A lifeline for disadvantaged communities
Many people in India cannot afford health insurance or to pay for surgery that their child may have needed for many years. These families depend on charities such as Johar Gesellschaft Deutschland, which is well known across the Jharkhand region for delivering services that are free at the point of use. The charity has been running the Asha Vihar development aid project near Ranchi since 1996, providing conventional medicine, physiotherapy and alternative medicines – such as acupuncture, homeopathy and Ayurveda therapies – to the poorest families. It introduced ‘surgical camps’ in 1998, and its hospital is a much-valued source of employment in the area, with approximately 100 paid staff. Asha Vihar also runs humanitarian outreach projects to local villages, a computer school, an orphanage, and satellite clinics in the surrounding areas for people who are unable to travel for treatment.
Heading into the unknown
Anaesthetists from Germany and Austria have long been involved with the Asha Vihar project. Dr Lukas Fischer, an anaesthetist at the HELIOS Klinikum ‘Emil von Behring’ in Berlin – which has a focus on paediatric orthopaedics – learned of the charity from a colleague, who explained how fellow anaesthetists were taking leave from their day jobs to make short trips to India to work at the surgical camps. He volunteered his services and joined the team for the first time in January 2019. Never having undertaken a trip of this nature before, Dr Fischer did not know what to expect. He explained: “I was quite nervous when I got there. Apart from some phone calls beforehand, I didn’t know any of the team, and was unfamiliar with the region and the culture. It was a very new adventure for me, and I really didn’t know what I was heading into, but it turned out to be a wonderful experience.”
Annual surgical camp
The surgical camp primarily focuses on individuals with deformities of the feet, and runs annually for six to nine days, usually in January when the climate is least humid. In 2019, the volunteer surgical team, headed by Dr Hans-Georg Zechel, successfully treated 26 children aged between seven months and 16 years. “The most common type of deformity was club foot, but also deformities of the lower legs, such ‘tibia vara’ (Blount’s disease), a growth disorder of the tibia that causes the lower leg to angle inward, resembling a bowleg. We also treated two children with malunions of previous fractures that required correction, and one with changes to the shape of the bone due to osteomyelitis, probably as a result of underlying tuberculosis.”
A child in need
The prevalence of such conditions in older children was new to Dr Fischer: “In more developed countries, these conditions are recognised at birth and usually treated by casting the child’s ankles or hips; in most cases surgery is unnecessary. However, the children we saw at the surgical camp live in very remote areas; they are born at home and many do not see a doctor for the first few years of their lives. For a child with club foot, for example, surgery is then the only option, as the bones and ligaments become solid a few months after birth and are no longer pliable enough to treat with a cast. The children we helped at the camp would simply not feature as surgical patients in most European countries.”
The social stigma of deformities
The children coming to the surgical camp were living a life of pain, with impairment to their everyday activities and limits to their emerging independence. As well as the physical consequences of the disability, the team recognised the impact that the deformities would have on their prospects in the future. Dr Fischer recalled one memorable case: “I remember a 14-year-old boy with a severe limp. As a teenager, he was obviously very aware that he looked different to other people his age, and you could just tell how handicapped he felt, and that he was most likely being bullied because of the limp. In India, people with a disability often end up not participating in society. It is extremely difficult to find employment if you have a deformity and, with a culture of arranged marriages, this young man was unlikely to be favourably considered as a potential match. The whole team was acutely aware of how important the surgery was for him, and fortunately he had a great outcome. I found the whole experience very rewarding, as it felt like we were significantly changing the path of someone’s life for the better.”
Taking POCUS everywhere
Dr Fischer knew that the approach at the surgical camp would be to use regional, rather than general, anaesthesia, and so made it a priority to source a portable ultrasound device to take with him to support this. “I am familiar with several POCUS devices, and find that FUJIFILM SonoSite machines offer a very clean picture. The company kindly loaned me a SonoSite Edge II for us to use, and its portability was perfect for this trip; I simply carried it onto the plane as hand luggage. It is also very quick and easy to clean – another important consideration in a potentially infectious environment. Once there, I was even more grateful to have it because a general anaesthetic was out of the question, both because many children were suffering from latent colds, and because the hospital’s ventilator did not function reliably.”
POCUS-guided regional anaesthesia
The team worked 12-hour days, operating for a total of seven days but, in contrast to his job in Germany, Dr Fischer did not feel under the same time pressures: “My colleague Dr Lembach and I had all the time we needed to properly prepare the children for surgery. With sufficient premedication through the rectal route, they easily tolerated insertion of an intravenous cannula and spinal block and were breathing spontaneously throughout the procedure. Since spinal blocks don’t last very long in children, we supplemented them with either a caudal block for bilateral surgery, or a femoral or sciatic nerve block if only one leg was involved, at the end of surgery. We used ultrasound to guide the blocks, and it was very reassuring to be able to see that the needle was in the right place. Our youngest patient weighed only seven kilogrammes, so the anatomical structures were very tiny, and we could also see the anaesthetic spreading around the nerves. We had a nerve stimulator with us as a back-up if we were struggling, but we never needed to use it; POCUS consistently and clearly allowed us to identify where the nerves were. We also occasionally used ultrasound imaging to help us diagnose severe abnormalities of the spinal column.”
POCUS helps deliver successful outcomes
Looking back, Dr Fischer highlights the indispensable role of POCUS in all the surgeries performed during the camp: “I honestly feel that I would not have accepted the mission had I not been able to take a POCUS device with me; it would not have been clinically safe to do so in light of general anaesthesia not being possible. Now, I can reflect on the lives of the 26 children we treated at the camp and feel that I played a part in restoring their hopes and aspirations for the future.”
