Biratnagar Eye Hospital

The next stop on the fellow schedule for the year is Biratnagar, Nepal, at the Biratnagar Eye Hospital (BEH). BEH is part of the Eastern Regional Eye Care Program (EREC-P), a non-profit group that is part of a 33 year collaboration between Nepal Netra Jyoti Sangh (NNJS), the Social Welfare Council of Nepal, and Christian Blind Mission (CBM). The first hospital in this system to open was the Sagarmatha Choudhary Eye Hospital (SCEH) in Lahan, Nepal, and BEH was later opened in 2006 due to the overflowing volume of patients in SCEH. BEH serves the southeastern region of Nepal as well as northern states of India, and even Bangladesh. Over a thousand patients arrive every day in their busy season, with up to 450 of them receiving same-day or next-day cataract surgery. A full spectrum of subspecialty clinics makes sure that no disease goes unmanaged.

My first day I was greeted by Dr. Sanjay, the hospital director and head of the cornea service. To say that Dr. Sanjay is a legaend in Nepal would be an understatement. He played a key role in the growth of Lahan Eye Hospital, and was the head of the project that opened BEH. Dr. Sanjay has operated on over 250,000 eyes, performing everything from high-quality small incision cataracts surgery (SICS) to pterygium excisions, pediatric cataracts, and corneal lamellar surgery. At a pace of one SICS every 2-3 minutes, he flies through 15-20 surgeries an hour performing consistently perfect techniques. Dr. Sanjay taught me on my first day how to create a DSEK graft with manual dissection, when modern keratomes or eye banks aren’t available to do it for you. As one of the senior surgeons commented, he has “beautiful hands” meaning that every movement is perfect and precise, without an extra move out of place, exactly as intended. There are few surgeons in the world who can boast such surgical volume and it’s only in places such as BEH or Lahan that a surgeon can reach such high numbers thanks to a well constructed system.

BEH has multiple training programs including a residency in it’s third year, anterior segment fellowship, cornea fellowship, and retina fellowship. The anterior segment fellowship is a 2 year surgical training program for those who graduated from residency in Nepal or India, and provides an unbelievable volume of surgery for young physicians. As a point of reference, the average resident in America may perform 100 – 250 cataract surgeries. The two year fellows will graduate with between 10,000 and 15,000 cataract surgeries under their belt, and a number of other procedures including pterygium excisions and dacryocystorhinostomy. While the training program is geared towards high-volume cataract surgery, the fellows are still able to gain competency in modern phacoemulsification techniques, often performing over 1,000 cases in their second year.

For those who have not visited a high volume cataract center such as BEH, these numbers can seem impossible – how can one surgeon do so many surgeries in such a short period of time? What it comes down to is efficiency. Every step of ever surgery, every material used, every team member, and every hospital employee has been focused in making the hospital a finely tuned machine. The operating rooms have two beds per surgeon with a microscope that swivels in-between. An outstanding scrub nurse is in charge of each table – making sure the patients arrive when necessary, are properly prepped and draped, all the surgical tools are laid out and ready to go, and are the maintainers of sterility throughout the process. In this way, the doctor will only spend a few seconds moving from one case to the next, in contrast with an American operating theater where turnover between cases can take anywhere from 5 to 30 minutes depending on the protocol of the surgical center. In coming posts, we will discuss further in detail how these feats are accomplished and what efficiency and community health look like in Nepal.