The emergence of Enhanced Recovery After Surgery (ERAS) nearly two decades ago has revolutionised perioperative care. The effectiveness of ERAS stems from its pathophysiological basis of perioperative stress reduction and preservation of physiological function in the postoperative patient. ERAS guidelines are designed to reduce the development of insulin resistance, a measure of postoperative stress and a major culprit in the development of postoperative complications. Studies measuring levels of systemic inflammatory markers after surgery showed lower levels of interleukin-6 and C-reactive protein in patients within an ERAS programme compared to those who went through traditional care. This decrease in stress response has been borne out by significant reduction of postoperative complications and length of stay in ERAS programmes across various surgical subspecialties.

Beyond its pathophysiological basis, a key but often overlooked aspect of ERAS is the philosophy of breaking down traditional models of perioperative care. These fragmented, siloed systems are a huge source of waste and unwanted variations in clinical practice, contributing to suboptimal outcomes. The ERAS concept of perioperative care brings all the stakeholders in the surgical journey together, patient included, working towards common goals through better communication, collaboration, shared responsibility and accountability.

Challenges and strategies in ERAS implementation

The success of an ERAS programme is dependent on more than just having a protocol in place. The implementation process itself is just as crucial, or arguably, more important. Common barriers to implementation have been identified as resistance to change, lack of time and staff, and poor communication, collaboration, and coordination between departments.

Having established a successful ERAS programme for various subspecialties in my hospital, and helping others in the region start their programmes, I would propose four fundamental principles that need to be present in establishing an ERAS programme.

The first is the ERAS team. This seems like common sense, but many fail at this stage because of a lack of buy in from the various stakeholders in the programme. It is vital that a team of multidisciplinary clinicians, consisting of at least a surgeon, anaesthesiologist and a nurse lead this team. Members of this team must also believe in the value of ERAS and work well with each other. This transdisciplinary collaboration is not a transient marriage of convenience but a long-term commitment to own and drive the programme from its conception to fruition, and beyond.

Second is getting hospital management support. Many clinical quality improvement projects start as pilot projects, and end as pilot projects. One of the reasons for this is the lack of will and resources to sustain. Ideally, support from hospital management should be present from the beginning, but many programmes start as a ground up approach. In these situations, initial positive results from the programme should help convince hospital management to back the programme and invest required resources, such as manpower, protected time for the staff involved to sustain and scale.

 Third is having a systematic model for implementation. It is often hard enough to institute a single change in clinical practice, but to bring about change to an entire suite of more than 20 practices will take change management strategies that enable existing systems to embrace new changes as seamlessly as possible. This means getting the team of multidisciplinary stakeholders together, going through micro workflows of the perioperative journey, eliminating excesses and unwanted variations and implementing evidenced based practices. This process needs to be constantly reviewed and improved, more regularly at the start, and then less so once a steady state is achieved.

Fourth and final is audit. You cannot change what you don’t know, and often we think we are better than we really are. Audit is the only way to know your outcomes. More than just outcomes, monitoring the compliance to the ERAS protocol has been one of the crucial tenets to the success of an ERAS Programme. Einstein said that “The definition of insanity is doing the same thing over and over again, but expecting different results.” To know how to improve outcomes, you need to know how they were derived. If the outcomes are poor and yet little is known about the process, then the likelihood is that the same mistakes will be repeated. Many centres claim to be practising ERAS, but do not have data to show for it. Only by having data, and using it in meaningful ways, will allow for improvements to be made.

The work doesn’t end with implementation. In fact the real challenge begins after implementation, in sustaining consistent standards of care and results. Even units that have undergone training in implementation have found sustaining a high level of compliance to the protocol difficult. Some of the difficulties in sustainability include staff burnout, high staff turnover, and lack of hospital management support and resources.

Ongoing issues in ERAS

One frequent concern about ERAS is the increasing complexity of the protocols. From the first published ERAS guidelines for colonic surgery in 2005 with 16 elements, ERAS Society has since published 12 surgical subspecialty guidelines comprising up to 25 components. This is a reason some have put forth explaining why ERAS implementation is fraught with difficulties, and uptake has been slower than expected. Furthermore, it is difficult to truly quantify the impact each ERAS element has on the outcomes. Certain elements, for example, minimally invasive surgery, has proven to be an independent factor associated with reduction in complications and better outcomes. Other elements on the other hand, have not been shown to have a significant effect on postoperative outcomes on their own. However, studies have also shown that a high level of compliance to the ERAS protocol has translated to better postoperative outcomes, implying that the ERAS components have a synergistic effect when performed well together.

Rather than perceiving ERAS as a protocol consisting of many individual, independent elements, it is perhaps more important to recognise that many of these elements complement and augment each other. For instance, by allowing oral clear fluids up to two hours before surgery, patients are more likely to be euvolemic when they arrive for surgery. This provides for easier and more optimal intravenous fluid management during surgery, which in turn reduces the adverse effects of dehydration or fluid overload. Similarly, minimally invasive surgery, by virtue of its other proven short term benefits of less postoperative pain, faster return of bowel function, directly enhances other ERAS elements such as opioid sparing analgesia, early enteral nutrition and early mobilisation. These interactions are not coincidental, as they all work to minimise the disruption to homeostasis and the stress of surgery to the patient.

Finally, the issue of value in surgery has to be addressed. Amidst rising healthcare costs worldwide, the value proposition of ERAS lies in its ability to improve outcomes, reduce complications, hospital length of stay, and thereby decreasing healthcare costs. Several health economic studies of ERAS programmes in single or multi-institutional studies have shown cost reductions that comes with successful ERAS programmes. At the same time, medical companies from the perioperative domains have jumped onto the bandwagon, introducing products and technology that seemingly improves care along different parts of the ERAS workflow. Ironically, these usually come with added costs, many significantly. Therefore, it is crucial for clinicians to critically appraise these new products and determine if their addition truly adds value for the patient, based on the risk, benefit and cost equation. It is possible that some of these new developments will indeed improve patient outcomes, but others not so or only in a subset of patients with high surgical risks.

While these issues continue to be debated, what cannot be denied is the unprecedented attention that ERAS has brought onto perioperative care in the last 20 years. This focus needs to be unrelenting. New and emerging evidence in perioperative care needs to constantly and rigorously be reviewed, to distil signal from noise. ERAS protocols have to be continually updated to stay relevant, never losing sight of its original and primary focus of improving patient recovery from surgery. 

References available on request.

Hearing loss, which worsens with age, affects more than 360 million people worldwide. This is about 5 per cent of the world’s population. Everyday people are at risk of hearing loss due to recreational noise, not to mention there is a growing number of undiagnosed people who are unaware of this issue. In the UAE, there are a significant number of people affected by deafness and hearing disabilities, which is why more and more awareness campaigns are coming to light on the subject. Hearing loss does not only affect immediate perception, but can also contribute to cardiovascular diseases, high blood pressure, hypertension and even dementia.

Looking at recent numbers from the World Health Organization (WHO), roughly half of people aged 12-35 are at risk of hearing loss. That’s due in no small part to the explosive growth in “personal listening devices”. Young people in particular are nowadays wedded to headphones and love to crank the volume up. Whether at the gym, at a concert or in their own cars, they are rarely aware that exposure to loud music could be doing irreparable damage to their hearing.

There’s a lot of evidence to show the more a person is aware of the effects of noise on their own hearing, the more likely they are to make changes and do things to protect it. It is really up to individuals and big industries to create a badly needed change. Companies such as Apple have made it easier to recognise loud noises in the future by examining factors that impact hearing health. The Apple Hearing Health Study is the first of its kind to collect data over time in order to understand how everyday sound exposure can impact hearing. The study data will collect information to make sense of how exposure to sound can affect hearing over time.

Nelly Attar, 29, owner of “Move Riyadh Studio”, Saudi Arabia’s first dance studio, loved her music loud in her younger days. She says “I used to always blast music in my ears to dance, put the highest volume in my car and go out often to places with very loud music. I took my ears for granted for many years thinking nothing could go wrong”.

She shares: “I remember having a very bad ear infection one time and going to a friend’s birthday celebration. Once safely back home that night I started experiencing a ringing sound in my ears. Since then I developed tinnitus permanently, it’s been eight years now”.

Tinnitus is a sound in the head with no external source that may come from one or both ears, from inside the head, or from a distance. It may be constant or intermittent, steady or pulsating.

Attar adds “My ears were delicate and fragile and long exposure to loud sounds throughout my teenage years prompted me to develop tinnitus. I had warning signs, but if you don’t know how to read those signs, you continue to ignore them until it’s too late.”

Today, Attar tries to make healthy lifestyle choices for healthy ears for her and her trainers. “I am glad to have the Noise app at the convenience of my wrist with my Apple Watch to help me measure and monitor not only the music volume but also the noise environment around me”.

She highlights: “All my trainers at Move are also instructed to follow the same for their own health and the health of our clients. I want them to have fun, listen to music, and dance, but also take care of their ears”.

Stephan Jansen Van Vuuren, 41, a Dubai-based Air traffic controller, shares “Given the nature of my job, I undergo stringent medical examination on an annual basis where my eyes and ears are tested. It was during one of these tests that I noticed a bit of a loss. My doctor at the time suspected the sound of the rifle fired during my Military service caused the initial damage to one ear, the one closest to the rifle. But later on, I suspect loud music, aircraft noise at air shows and the noise of a hairdryer I use to leave “on” to help me fall asleep, have also contributed to the damage. Today, any sudden unannounced loud noise would give me such a fright that I would lash out if it was created by a person in my proximity”.

Dr. Lubaina Sharafally, a clinical audiologist at the American Hospital says “It’s so encouraging to see how Apple Watch Noise feature can assist one to identify noise and limit the effects of noise exposure, as noise can damage hearing in a silent manner and create irreversible loss leading to severe communication difficulties”.

Dr. Sharafally explains, “People exposed to noise levels over 85 decibels for long durations are at an increased risk for acoustic trauma. This trauma can occur in a work setting, aviation industry, oil & gas or construction where individuals like Stefan are exposed to loud noise for long durations repetitively”.

The doctor further cautions, “Recreational noise exposure is commonly seen in people who like to go to shooting ranges or noisy clubs without exercising any hearing protection i.e. ear plugs or earmuffs. Need for hearing conservation i.e. earmuffs, customised hearing protection, ear plugs apply to all ages and to any person who is exposed to loud sounds or noise. Once hearing is lost, it won’t come back, so it’s important to understand the hazards of noise exposure, practice good hearing health and protect your hearing for life.”

So, what are the available solutions to protect hearing and limit hearing loss? Here are simple preventive lifestyle changes or actions one can make to save their hearing and prevent permanent damage.

Listen to what your ears are telling you

If you start hearing or experiencing buzzing or ringing sounds in your ears it is a sign that you should give your ears a rest, allow yourself a day of peace and quiet and turn the volume well down in the future. The new Noise app on Apple Watch, alerts you when things are getting a little too loud and decibels rise to levels that can impact your hearing. It also uses built-in microphones to measure the noise levels in your environment anytime. This information will then be logged into your health app as either “OK” or “Loud” based on guidance from the WHO.

Learn the 60x60 rule

Everyone loves music, but since the combination of volume and length of listening can cause major damage, researchers recommend listening to music at 60 per cent of the maximum volume for no more than 60 minutes a day. Ears that get a rest have time to recover and are less likely to be permanently damaged. Same rule applies if you are sending music directly to your ears via headphones.

Use volume control and sound check on your device

Aware of consumer concerns, some companies offer a volume limit setting. In Apple, for instance, you can go to Settings>Music>Volume>Limit and adjust the maximum volume you would allow yourself. Alternatively, you could use the iPhone’s Sound Check feature, which when turned on will give a better music-listening experience but also protect hearing.

Use noise-dampening or cancelling headphones

If you are listening to music via headphones, the noise around you may push you to turn the volume up, increasing your chances of hearing loss. To avoid the habit, it could be worth investing in some noise-cancellation earphones like the AirPods Pro, with which noise-cancellation will cut other external unwanted sounds, so a lower volume is needed to still enjoy the same audio experience.

Have ear protection on hand

There are many different ways to protect your ears. Hearing protection comes in various types, including ear plugs, earmuffs or molds, wadding and headphones. Always have an option on hand, especially when you know you’re heading to a loud place.

Obesity and metabolic disease have reached pandemic proportions; yet to date non-surgical treatment modalities focusing on lifestyle interventions or pharmacotherapies have limited success and impact on the metabolic consequences of obesity. To put this in perspective, the prevalence of type II diabetes and fatty-liver disease has risen significantly globally and is currently afflicting about 30 per cent of the world’s population.

Bariatric surgery has not only offered a select group of patients with obesity effective and durable weight loss, but ushered a better understanding of the role of gastrointestinal tract in regulating energy intake and metabolism through weight-loss dependent and independent pathways, coining the term “metabolic surgery” that is applicable to metabolic disease, such as type II diabetes, and non-alcoholic fatty liver disease. Penetrance of bariatric surgery, however, remains low at 1-2 per cent of eligible patients creating a significant management gap for patients with mild to moderate obesity with body mass index (BMI) between 30-40 kg/m², or those with severe obesity (BMI ≥ 40mg/kg²) who do not wish to pursue bariatric surgery.

Similar to the field of cardiovascular medicine, where angioplasty and stenting through a minimally invasive interventional cardiology approach bridged the gap between medical and open heart surgery for the management of coronary artery disease, the field of bariatric and metabolic endoscopy ushers a new wave of minimally invasive and effective tools for the management of obesity and its metabolic complications, which will complement medical and surgical approaches. Capitalising on selective targeting of similar peripheral and central gastrointestinal pathways, endoscopic bariatric and metabolic therapies (EBMT), can reproduce the benefits of surgical interventions in a minimally invasive, organ-sparing, and cost-effective manner. Furthermore, these devices and endoscopic techniques can be utilised in tandem or sequence to selectively target gastric and small intestinal pathways implicated in the pathophysiology of obesity, type II diabetes, and fatty liver disease.

Schematics of available EBMTs are demonstrated in Figure 1. Gastric EBMTs include space-occupying devices that most commonly take the form of temporarily placed prostheses. These include intragastric balloons, which can be liquid, or gas filled, and come in different unique designs and features. The TransPyloric Shuttle (BAROnova Inc, Goleta, CA), intermittently seals the pyloric channel and delays gastric emptying in the fed state to induce early satiation and prolonged satiety. The Full Sense Device (BFKW, Grand Rapids, MI), is a modified fully covered gastroesophageal stent with a cylindrical oesophageal component and a gastric disk connected by struts that exerts constant gentle pressure on the gastric cardia triggering afferent vagal signalling to the central nervous system and sensation of fullness resulting in weight loss. Additional gastric devices include gastric remodelling techniques that reduce the gastric reservoirs by creating an endoscopic tubular and short gastric sleeve along the greater curvature of the stomach with transoral endoscopic suturing (Overstitch, Apollo Endosurgery, Austin, Texas) or plication (POSE, USGI Medical, San Clemente, California). Finally, Aspiration therapy is a treatment approach for obesity that allows obese patients to dispose of a portion of their ingested meal via a specially designed percutaneous gastrostomy tube, known as the A-Tube (Aspire Bariatrics, King of Prussia, Pennsylvania).

Figure 1

The proximal small intestine plays a central role in the pathogenesis of type II diabetes and fatty liver disease orchestrated through a variety of pathways resulting in insulin resistance and chronic inflammation. These pathways include alteration of gut neurohormonal signalling, changes in the gut microbiome and mucosal barrier function, and activation of the gut immune system. Exclusion of the proximal small intestines by impermeable polymer duodenojejunal bypass liners (EndoBarrier, GI Dynamics, Lexington, Massachusetts) (Metamodix, Minneapolis, Minnesota) and ablative duodenal resurfacing techniques that regenerates the proximal small intestinal mucosal barrier by thermal and non-thermal techniques (Fractyl Laboratories, Cambridge, Massachusetts) (DyaMx, Plymouth, Minnesota) have shown promise and improvement in insulin resistance and fatty liver through weight loss dependent and independent pathways.

Finally, primary and secondary bile acids concentration and composition in the intestinal, portal and systemic circulations play an essential role in insulin secretion and resistance, metabolic rate, liver lipogenesis and inflammation, and liver fibrosis progression through FXR/FGF15 and 19/ TGR5 signalling. Self-assembling magnets for endoscopy (GI Windows, Boston, Massachusetts) creates a dual-path enteral bypass between the proximal jejunum and ileum; thus, partially diverting bile to the terminal ileum resulting in diabetes and fatty liver improvement.

Obesity impacts multiple common conditions gastroenterologists manage on regular bases. With advances in the field of bariatric and metabolic endoscopy, gastroenterologists will also participate in the management of obesity, in addition to managing its gastrointestinal complications such as gastroesophageal reflux disease, fatty liver disease, and gastrointestinal neoplasia. However, this can’t happen in isolation and has to occur in conjunction with colleagues from endocrinology, nutrition, psychology, and bariatric surgery to expand the toolbox of therapeutic offerings for patients with obesity and metabolic disease.

The word ‘doula’ — pronounced ‘doo-la’ — is a Greek word meaning ‘woman servant or caregiver’. Today, it refers to someone who offers emotional, informational and physical support to a woman and her partner before, during and after childbirth. A doula believes in ‘mothering the mother’ and enables a woman and her partner to have a satisfying and positive birth experience, from pregnancy and into parenthood. This type of support allows the whole family to relax and enjoy the experience too.

The role of a doula is somewhat new to the Middle East, however, it in fact dates back centuries with women supporting other women at its core. A doula, also known as a birth companion, birth coach or post-birth supporter, is a non-medical professional who is trained and certified in childbirth education and support.

A doula may provide some or all of the following services, dependent on her training and skills:

• Birth education and preparation

• Birth planning (including creating a written birth plan/birth preferences document)

• De-briefing previous births (if any)

• Massage and other comfort measures i.e Acupressure

• Suggest positions and changes to help ease pain and facilitate a smoother, more effective labour

• Provide reassurance and encouragement

• Talking through emotional blockages, which may come up during pregnancy and in labour

• Keeping a mother hydrated with beverages and snacks

• Keeping a mother’s ‘environment’ comfortable – aromatherapy, music, flameless candles etc.

• Assisting with negotiation of a mother’s labour and birth preferences

• Standard photography and/or video of the birth itself, as well as those precious first moments as a family

Does the UAE need doulas in maternity care?

The UAE is a great nation to promote new concepts as the vast majority of its population, regardless of the personal culture, is curious and open to discovering new information.

Doulas are a recognised profession in the majority of Western countries such as the U.S., UK, Brazil and Europe in general, and it was soon realised that many people and medical professionals were unaware of this unique role and the benefits it brings to a birthing couple and new families.

Being in Dubai, the majority of birthing couples are expats, who are away from their close family and friends, and so the option of having their mothers beside them during labour, may not be an option for many. Doulas tend to fill that void, as they present with a maternal approach that makes a woman feel safe and relaxed.

As women, we believe we play a huge role in the birth room, because we know that when women come together in difficult times or in times of need, amazing things can happen! It is that wonderful ‘woman’ energy that fills the room that helps a birthing woman feel calmer and more focused.

During the initial phase of setting up our company, Belly Baby Mom L.L.C, we introduced the Doula concept to several hospitals and medical professionals, and the feedback was very positive, which led us to approach the UAE licensing authorities to legalise the profession. After several months of discussion, in March 2018, Belly Baby Mom, became the first licensed Doula & Childbirth Support & Education agency in the UAE and the region, with a growing team of birth and postnatal doulas, childbirth educators, lactation consultants, baby massage instructors and more, supporting new and expectant couples throughout their parenting journey through classes, 1-1 labour support and target focused events.

Our main goal is to create awareness about the doula profession in the UAE and the importance for a birthing woman to feel and be respected, listened to and supported during her child-bearing experience.

The relationship between doulas and hospitals in UAE

We are well aware that some medical staff and hospitals are doubtful about the job role of a doula and its benefits for the mom and partner, however, we believe that the personal educational background has a big impact in how we are perceived. We find it very fulfilling when, after supporting a mom with her birth, and the medical team experiences first-hand what we do, they tend to become more relaxed in having us supporting their patients, as they see and understand what we do and how we really help the women have a more comfortable birthing experience.

It is a process that will take time, yet we are confident that our profession will be welcomed in different hospitals, as we have already secured partnerships with some of Dubai’s well-established hospitals.

Evidence-based benefits of doula support

Several studies (Cochrane, WHO, NCBI) have been conducted in the past years studying the impact of a doula’s presence during the prenatal and more importantly, the birthing experience. All these studies have reached the common result that, ‘to have a continuous professional birth partner (doula) staying at the side of a mother during labour and birth had several positive outcomes for both mother and baby.

Studies have shown that births have:

• 25 per cent decrease in length of labour

• 60 per cent decrease in Epidural Analgesia requests

• 50 per cent decrease in caesarean rate

• 40 per cent din Synthetic Oxytocin (induction) use

• 40 per cent decrease in forceps delivery

• 30 per cent decrease in Epidural Analgesia use

• 38 per cent decrease in a low five-minute Apgar score

• 31 per cent decrease in being dissatisfied with the birth experience

Source: Evidence Based Birth

“Of all the ways birth outcomes could be improved, continuous labour support by a doula seems like one of the most important and basic needs for birthing people. Providing labour support to birthing people is both risk-free and highly effective,” said a report by Evidence Based Birth.

How do mothers and doulas work together?

Belly Baby Mom offers a wide range of services for supporting women through the different stages of motherhood from early pregnancy and towards the first year of a baby’s life.

‘Doula support services’ include a personalised educational and emotional support service during pregnancy, birth and the postpartum period, and are split between ‘Birth Doula’ & ‘Postnatal Doula’ packages that a mother can choose between according to her personal needs and circumstances.

Typically, an expectant mother would contact us to be educated about what we do and how we can support them. A lot of the times, they seek recommendations for doctors and hospitals that are well experienced and that would be supportive of their birth choices. As doulas, we can only share our experiences and unbiased reviews with these mothers, while making sure they understand that every person is different and may gravitate towards one doctor over another. We always suggest that they visit a few doctors before making a decision on the selection of their care provider.

Birth doulas

The ‘birth doula’ offers two private prenatal sessions in the comfort of the mother’s home during which she becomes acquainted with the expectant couple and discusses the couple’s birth wishes regarding the birthing experience. These sessions are tailor made on the couple’s needs, as some prefer them to be more educational whilst for others, they could cover pain relief techniques (medical and natural coping techniques), what to expect at the hospital, signs of labour etc.

It is important to note that the doula from this point onwards, becomes the couple’s “Maternity coach” and is available to provide non-medical advice and emotional support through phone, messages and emails.

From the 38th week of pregnancy, the doula is on call 24 hours a day and 7 days per week, ready to be called to join the mother at the hospital at the start of active labour and when she is requested to be present. The doula remains with the mother in hospital providing ‘continuous labour support’ until one hour after the birth.

The doula returns back to the mother’s home within a week from birth, for a private postnatal session to support her with understanding her new role as a mother, as well as to debrief the birthing experience.

“Birth is not only about making babies. Birth is about making mothers strong, competent, and capable mothers who trust themselves and know their inner strength,” a U.S.-based professor, Barbara Katz Rothman, was quoted saying.

Postnatal doulas

Postnatal doulas offer a personalised service to the new mother through a vast array of services stemming from different traditional practices. The aim of a Postpartum Doula is to comfort and hold the new mother’s space for her to have more clarity about her new role as a mother, fostering a healthy relationship with her baby and supporting her with her own mothering decisions, without imposing any personal believe or ideology. The postnatal doula can also provide informational and practical support on healthy breastfeeding practices, diaper changing, baby sleep, emotional well-being and more.

For many mothers in the UAE, especially the ones who are willing to take care of their baby by themselves, it is very important to have a supporter in the first days of motherhood in order for them to find their own path whilst being supported professionally and through the latest evidence based information available. The support of a ‘Postnatal Doula’ is typically presented in 10-hour packages that a mother can avail.

Are doulas medical professionals?

Doulas are trained and experienced in childbirth support and the physiology of birth and are usually mothers themselves. While they have good knowledge and awareness of the birth process, a doula does not support the mother-to-be in a medical role, as that is the job of the midwife or doctor. A doula helps the mother-to-be to achieve the birth she hopes for, no matter if it’s a birth with or without medication, or even a c-section. This makes a doula a valuable addition to the birth team, who are all there to support her and her choices.

The most important value for us as doulas, and why we believe it is beneficial for birthing mothers, is that we tend to hear of many negative birth stories, and for which we feel many could have been avoided only if a mother knew a little better.

As doulas, a lot of the times we cannot change a birth outcome, especially if a medical procedure is suggested and is necessary, but we make sure that parents know that they have a right to ask questions, evaluate the benefits and risks, and more importantly have the right to accept or decline. This is crucial, because many women in the UAE suffer post-natal depression because they feel they have failed their babies and themselves or feel guilty for making the wrong decisions. In the end, we are also there to comfort a mother and talk to her about her own birth experience and how she feels about it, which is an important step in healing, should she have had a negative birth experience.

References available on request.

Karen Bluemke spends as much time as possible these days soaking up the sun in Florida. After completing treatment for pancreatic cancer, she decided, it’s “time to finally have some fun.”

“Why wait for retirement?” said Bluemke, who is in her mid-50s. A triage nurse, she is able to work remotely from the oceanfront condo she and her husband recently purchased.

Bluemke learned she had a tumour in her pancreas in March 2016. “The first oncologist I saw painted a grim picture,” she said. She turned to the University of Chicago Medicine and surgical oncologist Mitchell C. Posner, MD, for a second opinion.

“Dr. Posner was fantastic,” she said. “He had so much experience. I went from devastated to hopeful.”

Because pancreatic cancer is usually detected late, often after the disease has spread, it has a poor prognosis.

“A pancreatic cancer diagnosis is life-defining,” said Posner, who has more than 25 years of experience in the surgical management of the disease. “Our philosophy is, that at the very least, every patient deserves hope, even when there seems to be little.”

“Karen came to us a young woman with an advanced, but treatable cancer,” he said. “We had something to offer.”

The malignant tumour was in the “head” of Bluemke’s pancreas. The cancer had spread to one lymph node and involved the portal vein, but no other organs.

After a four-month course of chemotherapy shrunk the tumour, Posner determined Bluemke qualified for surgery.

In June 2016, Posner’s team performed a Whipple procedure, the most common surgery to remove pancreatic tumours. However, only about 20 per cent of patients are candidates for the procedure based on the stage of their cancer. The University of Chicago Medicine is one of the few hospitals in the U.S. that offer the Whipple procedure using both traditional (open) and minimally invasive robot-assisted techniques.

The surgical team removed the head of Bluemke’s pancreas, sections of the small intestine and portal vein, her gall bladder and part of her bile duct. The remaining portions of the pancreas, bile duct and small intestine were then reconnected to restore function to her digestive tract and the portal vein was reconstructed.

After recovering from her surgery, Bluemke underwent another course of chemotherapy, completing treatment in December 2016.

Bluemke has been cancer-free since then, but has regular blood tests and scans to look for signs of the cancer coming back. Posner will continue to follow her.

“All my thanks go to Dr. Posner,” said Bluemke. “What a great person to be with when you get that diagnosis.” 

For more info visit: https://www.uchicagomedicine.org/global

Arthroscopic surgery for Osteoarthritis (OA) knee is not a new concept. In fact, in the past 50 years or so, before the widespread acceptance of Total Knee Replacement (TKR), Arthroscopic surgery, along with High Tibial Osteotomy occupied a prominent place in the Orthopaedic surgeon’s arsenal. These surgeries were (and still are) in sync with the socio-cultural requirements of our patients. This is most useful in Asiatic cultures that require squatting for toilet, sitting down on the floor or kneeling for prayers. Walking on uneven surfaces and negotiating staircases, again a prominent requirement in these countries, requires a high degree of proprioception that artificial knees cannot achieve for obvious reasons.

Arthroscopic surgeries for predominantly mechanical symptoms like locking and give-way sensations have always been a success on short-term basis. Unfortunately, long term results of Arthroscopic surgery in OA Knee were not very exciting. This could probably be attributed to the lack of specific criteria (age, activity level, extent of cartilage damage and patient expectations) and available operating instruments at that time.

That was a pre-MRI era, where pre-op diagnosis of extent of cartilage damage was inaccurate. But, for want of anything better to offer to the patient, even Tricompartmental OA underwent Arthroscopic surgery, or sometimes even joint lavage. This approach could not provide expected relief to patients.

Moreover, by today’s standards, the available surgical tools were inefficient and crude, so that a lot depended upon an individual surgeon’s skill. This led to an impression that doing Arthroscopic surgery for OA Knee was not much better than a placebo or worse still same as doing a sham surgery.

When TKR burst upon the scene, a generation of surgeons, at least in India, largely felt that beyond conservative therapy there is only TKR. Even today in academic meetings on OA knee, Arthroscopic surgery and High Tibial Osteotomy are only cursorily discussed.

Has this extreme approach of directly jumping to TKR, once a conservative therapy, irrespective of the age of the patient and condition of all compartments of knee, solved our patients’ problems? Of course not!

There is a huge mismatch between what the patients expect from the surgeons and what they can give them. Instead of modifying our treatment methods to cope up with their socio-cultural requirements, we just impose a ban on a whole set of activities on them.

Recent literature highlights a high degree of dissatisfaction after TKR at an early age, i.e. between 50 to 55 years.

What about the Hiflex design that is supposed to be the panacea for Asiatic knees? Bollars et al in JBJS 2011 has analysed the unsatisfactory results of these implants. Moreover, their longevity claims are based not on actual data but on computerised predictions.

Consider these well-known facts about OA Knee

• Life expectancy today is 75+ years
• Optimal life of primary TKR prosthesis is 12-15 years
• Revision TKR has problems of technique, cost and rehabilitation
• OA knee onset is at 50+ years

Hence, we must find a different solution for these patients between 50-60 years, with failed conservative therapy, demanding good function from their natural knee, at the peak of their professional careers and too early to consider a TKR. If we do a primary TKR not before 60 years, we can hope to avoid a revision TKR for that patient.

Laser assisted Arthroscopic surgery with correction of Biomechanics provides a logical solution to these patients. Laser promises to fill up a huge lacuna in our armamentarium. It has many advantages over the suction-shaver and the radiofrequency apparatus.

Important aspects of using Laser

1) Laser technology is for intra-articular use and therefore used as an Arthroscopic surgical tool. It is not an alternative to Total Knee Replacement. Using this technology does not prevent a TKR, but it has the potential to postpone TKR by a significant period of time. This has valuable implications in the 50-60 age group.

2) This technology should not be viewed as the latest Gizmo in town. Our time-tested tools do retain their value. Using Laser does not make a bad surgeon good, but it can vastly improve the results for a good surgeon if used in a judicious manner.

3) This surgery is NOT indicated in Tricompartmental OA of the Knee, where TKR is still the Gold standard.

Use of Laser in Arthroscopic Surgery of the Knee

Laser technology was first commercialised for military purposes in the 1960s in the U.S. Later on, civilian applications inevitably emerged. There are now more than 10 different types of laser’s available for Medical use.

Laser in general uses the principle that energy is not destructible but convertible from one form into another. Here, electrical energy is converted into light energy. Both theories of light (particle and wave theories) are used, that is a Photon beam of single wavelength is focused onto a target tissue by transmission through a fibre, which is similar to the fibre optic cable used in Endoscopy.

This photon beam interacts with tissues in different ways, producing various effects on them. This has tremendous clinical implications.

The Holmium: YAG LASER works in a liquid medium and hence is suitable for Arthroscopic and Urology applications. This is a Laser beam with wavelength in infrared spectrum, i.e.2100 nm.

Laser energy is transmitted to the target tissue through a fibre of diameter 350 microns, inserted into the joint through a needle probe of diameter 1.8 mm.

Interacting with the intra-articular tissues, it has following effects:

Photothermal effect

When fired from a distance, it can slowly heat up the collagen fibres and denature them. This is of value in shrinkage of loose capsule and ligaments. This is useful for superficial shrinkage of cartilage during cartilage contouring or Chondroplasty

Photoablative effect

Here, a laser fibre in contact with tissues can ablate them by bursting cell walls without formation of free carbon radicles. The fibre-tip temperature is 900 degree-C, so that sealing of surrounding bleeding vessels is easy. This is useful in Synovectomy in Rheumatoid, Psoriasis, Gout and Haemophilia.

This is also useful in Adhesiolysis in post-trauma situations. This can prevent rapid onset of Secondary OA.

Electromechanical effect

Again, a contact beam application is useful in excision of Osteophytes and bony prominences as in Patello-femoral joint and Footballer’s ankle. A major use in OA Knee is for Micro fractures in various situations where multiple areas are involved, as against ACT.

In all these situations, minimal or no residual joint debris is a stand-out feature of LASER usage. Hence, postop synovitis is minimal; morbidity is low, and rehabilitation is faster.

Advantages of using Laser for Arthroscopic Surgery of the Knee

The Holmium: YAG LASER has many advantages over a suction-shaver:

• Minimal tissue debris
• Haemostatic effect
• Minimal collateral tissue damage
• Can do bloodless Microfracture easily
• Osteophyte excision easy
• Can reach crevices of small size knees easily

Simply using LASER will not give good results in Arthroscopic surgery for OA Knee. Three more aspects are equally important:

1) Clinical suspicion of cartilage-at-risk situations

2) Early diagnosis of cartilage damage by MRI scan or Cartigram

3) Correction of biomechanics of weight transmission by High Tibial Osteotomy whenever indicated and feasible

In conclusion, in the 50-60 years age group, where most patients with moderate OA (not Tricompartmental) lie, we must make every effort to increase the life and performance of the natural knee. The least that we owe these patients is to avoid a Revision TKR in their lifetime!

Simulation is a method in which the learners gain artificial and virtual experience in an activity that reflects real-life circumstances without taking the risk of real-life situations. Simulation offers an important route to safer care for patients and does so by improving performance, reducing errors, and strengthening teamwork.

The use of simulation in healthcare dates back to many centuries, where anatomical models were used to teach anatomy. In the 20th century, Asmund Laerdal came out with Ressusi-Anne, which was a result of collaborative work of anaesthetists and the industry. This manikin became an example for other models and designs in terms of resuscitation and basic skills education. Current practices of simulation used in healthcare include role-playing with simulators, simulated patients, computer-based simulation, simulation software, videos, DVDs, or creating virtual reality, computer-controlled simulators, and interactive patient simulators. Simulation-based education is a context that uses adult education principles effectively and appeals to different learning preferences. In these contexts, needs are defined by the learner and educator, and where the learners are engaged in learning by doing experiences.

The Khalaf Ahmed Al Habtoor Medical Simulation Centre

The Khalaf Ahmed Al Habtoor Medical Simulation Center at the Mohammed Bin Rashid University of Medicine and Health Sciences was established in 2011 and is the largest centre in the UAE.

The Simulation Centre is a society of simulation in healthcare. It is a fully accredited medical education and training facility, equipped with hospital-grade equipment to support healthcare professionals by providing an authentic environment to practice. It features part-task trainers, low medium and high-fidelity manikins to simulated participants, equipped with realistic environments, excellent moulage concepts, and clinical know-how.

The primary aim is to improve skills in patient care by creating a patient journey from pre-admission to discharge, showcasing realistic hospital environments and a clinical skills lab, to better educate student learners and the wider medical community.

Comprehensive and inclusive medical simulation

Beyond the expected scope of medical simulation centres focusing on training health professionals, our 360 Medical Simulation paradigm objective is two-fold: (i) Innovate in the use of simulation for health professionals (ii) Provide simulation-based learning opportunities to the community at large.

Impacting learning of in training healthcare professionals

Designed to support the education of healthcare professionals, the Simulation Centre provides 11 realistic hospital environments for students to learn and practice new techniques and patient care. Currently, simulation-based education is embedded right from the inception in the year 1 of the MBBS programme and the postgraduate Dental Programme. Future healthcare professionals are exposed to the full range of environments beginning from accident and emergency to consultation room experiences where they can learn and practice technical skills such as physical examination as well as non-technical skills like communication and courtesy.

Impacting practice of working healthcare care professionals

Over the years, multiple courses have been designed to serve the needs of various healthcare professionals ranging from school nurses to anaesthesia technologists. Infection prevention and control, mental health assessments, identification and management of acute emergencies in children are a few examples of the varied courses that are conducted for continuous professional development purposes among healthcare professionals. All these courses along with a theoretical component have a rigorous simulation exposure thus enabling the participant to physically and emotionally experience what he or she would do in the exact situation.

Introducing children to the healthcare environments

The first of its kind in the UAE, the Teddy Bear Hospital, was created to promote healthcare awareness and help children overcome their fear and anxiety of visiting a hospital. The Teddy Bear Hospital allows children to experience the journey of going to a hospital, along with their Teddy Bear, where treatments are carried out by healthcare professionals in patient wards and operating rooms. The children are dressed in white coats and are allowed to perform a general check-up on their bear; some of the bears are also chosen by the simulation staff to be examined in the respective areas. They can choose to play the role of a parent or help as a doctor and watch the medical procedures from a different perspective. The final wind up is with an interactive teddy bear game.

Inspiring high school students to become health professionals

The Destination Medicine@MBRU aims to encourage students interested in medicine and health sciences to visit the simulated hospital environment, interact with healthcare professionals, and learn Basic Life Support Skills. The students are oriented to the simulation environment and exposed to various components, not limited to vital signs, equipment used in an operating room, and are also involved in a simulation scenario. The Family & Friends component from the American Heart Association module is also covered during this session.

Opening the door to prospective healthcare students

Pulse Day is a programme that introduces high school students to the medical field through a series of activities, including medical lectures, exploring the research labs, and the Simulation Centre. Students get the opportunity to experience simulated medical scenarios and more.

Engaging our citizens in the training of future health professionals

People from the community who are interested in contributing to the development of healthcare professionals may be chosen to work as Simulated Patients. These individuals are carefully selected and trained to portray a real patient to simulate a set of symptoms or problems used for healthcare education and research. MBRU has a bank of 100+ simulated patients from 21 different nationalities and varying age groups

Enabling our citizens to save lives

The majority of cardiac emergency survivors attribute their second chance in life due to immediate life-saving measures, especially early CPR offered by bystanders. At MBRU, we train the community on how to perform Hands-Only CPR – so that they can help deliver life-saving care until professional responders arrive.

Moving forward

Immersive learning to provide simulation-based experiences beyond the physical borders of the centre and novel simulation modalities.

• Take the simulation to the community (in situ).
• Take a larger responsibility to support other centres through the training of their medical simulation professionals.
• Place Dubai as a global hub for medical simulation. 

References available on request.

Trauma is a significant cause of mortality and is one of the most common causes of death in those less than 45 years of age, in both High- and Low-Income countries. Worldwide around six million people lose their lives due to trauma. It predominantly affects young males and the loss of these productive members has a disproportionate impact on both their families and society; particularly as those injured and disabled by these events far outnumber those who lose their lives.

The National Trauma Institute in the U.S. estimates that the total cost in terms of healthcare and loss in productivity in just the country is US$671 billion, with up to 30 per cent of all potential life years lost before the age of 70 due to trauma.

As early as 1966, a report by the National Academy of Science called trauma the ‘neglected disease’ and became the driver for improved care of trauma in the U.S. However, the National Institute of Health grant funding for Trauma Research was only 0.02 per cent of its budget.

In Low-and Middle-Income countries, the lack of trauma infrastructure means the overall burden is much higher and it is estimated that potentially two million lives could be saved by better trauma systems and rapid access to higher quality care. This led to the World Health Organization (WHO) placing access to emergency care and development of Trauma Care as priorities on the 72nd World Health Assembly agenda in 2019 noting: “Whereas primary prevention remains the mainstay of public health efforts to reduce the toll of injuries, infections and noncommunicable diseases, many deaths and much long-term disability can also be prevented through strengthening emergency care. The World Bank Disease Control Priorities project estimates that more than half the deaths and around 40 per cent of the total burden of disease in low-and middle-income countries result from conditions that could be treated with pre-hospital and emergency care.”

Prevention is one of the key strategies to reduce trauma related death and disability and in this capacity governments, legislative agencies, local police forces, manufacturers of vehicle and safety devices, and medical establishments and local agencies have a significant role in informing the public and changing behaviours. However, sometimes the multitude of stakeholders makes coordinating action a challenge and in this regard, the importance of national and regional registries in collecting data and providing guidance on where to focus preventative strategies cannot be over-emphasised.

Ironically a lot of the improvements in the care of the seriously injured have come from lessons learned from war and conflict. It was during the Napoleonic wars that Baron Dominque Jean Larrey developed the concepts of triage that Emergency departments and Ambulance services still use. Further developments in trauma management followed during the American Civil War, World War 1 and 2, Vietnam and through more recent conflicts in Afghanistan and Iraq.

Rapid care

Though traumatic brain injury is a major cause of death and disability, haemorrhage remains the most significant cause of preventative early death. As the philosophy and technology of trauma management develop key courses such as Advanced Trauma Life Support (ATLS), there is a need to adopt these principles and evolve their taught content. ATLS was started in the 1970s under the auspices of the American College of Surgeons in order to improve trauma care and is now taught in over 80 countries worldwide. The course emphasises a standardised logical approach to managing trauma though there is room for further courses that deal with multidisciplinary team-based trauma management.

Clearly getting patients to the right place during the right time is a key element of trauma care and trauma systems. The London Major Trauma System, for instance, have shown an improvement in early trauma mortality by defining Major Trauma Centres and helping develop Critical Care teams that respond to defined major trauma events, carrying out critical life-saving interventions and transporting patients rapidly to the right facility for care.

Though some of these helicopter-based systems are very sophisticated, the principles of managing haemorrhage are not complicated. The most important principle is preserving blood. External haemorrhage is controlled using packing devices and tourniquets and though the principles of these are antediluvian, there have recently been significant advances in wound packing materials, which are increasingly impregnated with haemostatic agents such as chitosan. In addition, there are now a variety of effective tourniquet developed by the military to limit bleeding from limbs where direct pressure is ineffective.

Professor Karim Brohi, Professor of Trauma and Vascular Surgery, has shown that major trauma induced coagulopathy is a significant contributor to trauma related bleeding. The recognition of coagulopathy being integral to major trauma led to the development of Major Haemorrhage Protocols and development of a 1:1:1 transfusion strategy using packed Red Blood Cells (RBCs), fresh frozen plasma and platelets. However, there is a need to use more advanced point-of-care testing like Thromboelastography (TEG) or Rotational Thromboelastogram (ROTEM) in order to tailor treatments to the patient’s specific needs.

Antifibrinolytics now form part of the treatment in trauma and several large randomised controlled trials, in particular CRASH 2 and CRASH 3, have shown positive effect in survival of trauma victims when administered early after the onset of injury.

Technological solutions don’t necessarily increase costs, and drone-based delivery systems for critical medication, blood and equipment have been used in lower income countries. Malawi has been one of the pioneers of these systems and their use is now spreading among other countries. It is only a matter of time before elements of these systems will find their way into higher income countries’ systems of care.

Developments in imaging have also had a significant impact on accurate and early diagnosis of hidden injuries. Among these are the dissemination of point-of-care ultrasound, which as scanning technology gets increasingly portable and affordable, extend the accuracy of examination by the front-line physician. CT scanners with higher imaging resolution are also contributing to the rapid early diagnosis of injuries and have become integral to the assessment of people who have suffered major trauma. These scanners are increasingly being placed close to – if not within – the resuscitation rooms of major trauma centres.

Diagnosing and managing internal bleeding still remains a significant challenge but principles of placing pelvic binders, allowing permissive hypotension to limit blood loss and damage control surgery to ensure optimum resuscitation before definite repair of injuries have shown their merit in the theatres of war. Though interventional radiology is important to identify and treat internal sources of haemorrhage, its impact will likely increase as hybrid operating theatres, allowing surgeons and interventional radiologists to work in tandem.

Technology is increasingly allowing the development of smaller catheters and this makes it feasible for specialised skilled teams to intervene early in the critically ill patient. In particular, developments in catheter-based treatments such as Retrograde Endovascular Balloons to occlude the Aorta and limit haemorrhage (REBOA) teamed with technology allowing Aortic Arch perfusion (SAAP) or Extracorporeal Membrane Oxygenation (ECMO) allows physicians to salvage ever sicker patients. However, this will make it necessary for fully trained emergency physicians to be available round-the-clock, especially in designated centres.

Rehabilitation has also benefited from the technological and digital revolution and better prostheses ensure those unfortunate enough to have been victims are still able to lead fulfilled lives and return to being productive members of society.

Trauma is a disease that cuts across many specialties and stretching the whole medical system leads to better multi and interdisciplinary working. Eventually, the improved coordination between many different professionals and disciplines in solving these critical and time-dependent challenges leads to a more responsive system that eventually benefits all our patients.

References available on request.

The Institute of Medicine (IOM) report To Err is Human in 1999 revealed that medical errors are responsible for 44,000-98,000 deaths per year in the U.S. More than two-thirds (70 per cent) of the adverse events found were thought to be preventable – technical errors (44 per cent), diagnosis (17 per cent), failure to prevent injury (12 per cent) and errors in the use of a drug (10 per cent).

Factors leading to errors are divided into systemic and personal factors. Systemic or environmental factors like complex working conditions, lack of leadership support, lack of personnel, overtime, information flow and workload are common factors related to medical and paramedical personnel exposing the healthcare system environment to life threatening errors at many points of the therapeutic process. Personal or human factors such as lack of teamwork, poor communication, carelessness, fatigue, and competing tasks have a negative impact on team performance thus affecting patient safety.

Today, preventable harm is placed among the leading causes of death in the United States (IOM report 2000). This is considered a public health crisis. Hence, health systems stakeholders should collaborate and take action to prevent the harm resulting from healthcare.

The National Patient Safety Foundation (NPSF) calls for coordinated efforts between leaders and policy makers to trigger a public health response to ensure safety for patients in healthcare systems and mitigate the risks of preventable harm. The below framework (Figure 1) is their proposal, which they recommend for adoption by healthcare systems to guide efforts and propagate effective actions.

Improving patient safety activities are so far individual initiatives taken by hospitals in a non-consistent approach leading to diversified outcomes.

Today it is time to call for a more organised, structured and national approach that starts at the top by engaging all policymakers, governments, insurers and healthcare leaders to establish the necessary infrastructure, ensure patients are not harmed by adverse events, establish a blameless reporting culture and set measures to prevent harm at all levels.

The situation of Patient Safety in a developing country such as Lebanon is worrisome because of the unreliable supply of equipment and medications, the lack of protocols for infection control and waste management, the shortage in human resource capital and the financial restrictions on the healthcare system and its employees.

The Lebanese Society for Quality & Safety in Healthcare (LSQSH) is working in collaboration with the World Health Organisation (WHO) to motivate all Lebanese stakeholders and establish a national patient safety programme guided by the above-mentioned framework aiming for standardised practices and reduction in harm.

A group of experts studied the most frequent events occurring in the patient’s path in a healthcare system from admission to hospitalisation ending by the discharge, taking into consideration the risks present in the environment and the impact of human and behavioural factors including communication. A set of patient safety goals was established for each part of the journey. For each goal, a set of indicators was defined, and a target was identified.

Increasing awareness 

Assessment of the educational needs of the Lebanese community was done through a survey to study the knowledge of the population and see where we can interfere to increase awareness.

This study was conducted by the Lebanese American University (LAU) residents at two hospitals in Lebanon (one in Beirut, and one outside of it) where the survey was distributed to the Lebanese patients to assess their knowledge about their safety in hospitals.

Upon assessing for protocols related to hand hygiene, identification bracelet and marking the site of surgery, knowledge of those topics was suboptimal. Other protocols related to fall precautions and medication administration were very well known for the population. Although 76 per cent of the population knew about the protocols, only 32 per cent were willing to remind the providers about this protocol.

This discrepancy between knowledge and the willingness to participate in their safety reflects a possible sociocultural norm that influence the patients or visitors’ attitude and perception of the physician-patient relation.

Thus, awareness campaigns were directed towards educating the population about the importance of participating in implementing their own patient safety and ultimately work towards having patient safety an important element of patients’ rights.

The “Stay Safe” video and booklets were created and distributed within hospitals, scientific fairs, media announcements, social media and community educational activities… etc.

One year after community education and healthcare providers training, measurement of patient safety indicators was made available for hospitals. A pilot project was conducted with five hospitals aiming for a national and international benchmarking. Many challenges were encountered as unifying data collection tools and methods, anonymous reporting of the benchmarked results… etc.

Although Patient Safety measurement became a mandatory topic on the new Lebanese Standards for accreditation, today our work needs to be sustained with the support of policymakers, government, healthcare organisations, third party payers, professionals, patients and their families in order to maintain a national programme that encourages speaking up and error reporting while staying away from finger pointing. The ultimate goal being “Zero Preventable Harm for all Patients”.

A public health crisis? Yes. Each member of our society has a role in improving our healthcare system and in implementing the public health action plan. 

With some 165,000 new cases being diagnosed every year, the incidence of breast cancer has overtaken cervical cancer to become the most common cancer affecting women in India. What is even more alarming is that breast cancer is being increasingly diagnosed at a younger age (a decade earlier) in India, compared to the West. Due to lack of awareness and absence of an organised nationwide population-based breast cancer screening programme, more than 70 per cent of breast cancer in India is present in advanced stages, and as a consequence, majority succumb to the disease within a year of being diagnosed. With 87,000 deaths per annum, tragically, a woman loses her life to breast cancer every 10 minutes in India.

In 2002, whilst working in United Kingdom, my mother, Dr. Ushalakshmi was diagnosed with breast cancer. Her unexpected diagnosis coupled with a mission to work alongside like-minded colleagues to improve the delivery of breast healthcare in India became the defining moment in my life. The aim of this article is to share some of my goals that I translated to reality over the past 12 years, since relocating to India.

The ‘Breast Centre’ concept

Breast Surgery is now recognised as a subspecialty of General Surgery in the West with structured training for designated ‘Breast Surgeons’. There are recognised training Programmes in Oncoplastic Breast Surgery abroad and over the years, breast cancer care has been enhanced by the emergence of Specialist Breast Surgeon with training in Oncoplastic Surgical skills – Oncoplastic Breast Surgeon. Equally, there is robust evidence from literature to suggest that outcome of patients with benign breast disease and indeed breast cancer is best when they are managed by well-trained dedicated breast specialists within the confines of ‘Breast Centres’.

Mirrored upon the world’s first breast centre that was established in California, in 2007, I conceived, designed and established KIMS–USHALAKSHMI Centre for Breast Diseases, South Asia’s first free standing, purpose built comprehensive Breast Health Centre, which is located in Hyderabad, the capital city of the southern Indian state of Telangana. As nine out of 10 breast health issues are benign, the aim is to reassure the vast majority of “worried well” and treat those diagnosed with breast cancer in a multidisciplinary environment.

Breast Cancer foundation

Having identified lack of awareness as one of the main reasons behind high mortality for Breast Cancer in India, a ‘not for profit’ breast cancer Charity was founded during the same year (2007). Based out of the state of Telangana, the Foundation bears my mother’s name (Ushalakshmi Breast Cancer Foundation) to honour her struggle in the fight against breast cancer. Over the past 12 years, the Foundation has left no stone unturned in its mission to transform breast cancer from a “taboo” issue to a much commonly discussed one through a number of innovative initiatives, thus creating the much-needed awareness about ‘early detection’.

Population based breast cancer screening

With the singular aim of ensuring early detection of breast cancer and save more lives, Ushalakshmi Breast Cancer Foundation has implemented South Asia’s largest population-based Breast Cancer Screening Programme by way of Clinical Breast Examination (CBE) in 15 districts of southern Indian states of Telangana and Andhra Pradesh. Between 2012 to 2016, well over 200,000 underprivileged women between the ages of 35 to 65 years spread across 3,990 villages have been screened for signs of early breast cancer by 3,065 trained healthcare workers.

Breast cancers detected through this initiative have offered treatment free of cost through the state Government funded scheme. Impressed with this successful large-scale initiative, since the beginning of 2018, the Union Ministry for Health and Family Affairs has been implementing population-based Breast Cancer Screening Programme by way of CBE all across the country.

A dedicated breast surgical society – “The voice for breast surgery” in India

In an effort to standardise delivery of breast surgery and pave the way to develop breast surgery as a distinct subspecialty in India, The Association of Breast Surgeons of India (ABSI) was formed in 2011 mirrored upon The American Society of Breast Surgeons (the largest society of breast surgeons in the world), Association of Breast Surgeons in United Kingdom & Association of Breast Surgeons of Australia & New Zealand. ABSI is the first and only organisation in South Asia that represents General Surgeons, Surgical Oncologists and Plastic Surgeons involved in the management of breast disease.

Starting from 2016, the standardised ABSI Training Module is being rolled out in every state across the country, which aims to empower General Surgeons working in towns and villages on every aspect of delivering effective breast healthcare. ABSI also aims to create public awareness about the importance of early detection of breast cancer, strengthen the concept of ‘patient advocacy’, and equally, impress upon the Government of India that early detection of breast cancer must become a political priority.

Conclusion

There is a need for a paradigm shift in the management of breast healthcare in India. The concepts of breast centre, breast surgical society, breast specialists, breast cancer advocacy and implementation of population-based breast cancer screening are all bound to improve the delivery of breast healthcare in the country.

There are turning points in everyone’s life. Working towards accomplishing my vision in the country, that I was born and raised in, over the past 12 years has given me great satisfaction.