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The Cost of a Delay in Surgery

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Gnanakumari (3rd from left) and family in the neurosurgery ward of Sri Venkateswara Institute of Medical Sciences (SVIMS). Image by Priya Ramchandra. India, 2015.

The problem first started when M. Kotaiah, a farmer in his 40s, noticed that his 19 year old daughter Gnanakumari suddenly started gaining weight. Concerned, he and his family traveled from their village in the district of Nellore in southern Andhra Pradesh to Sri Venkateswara Institute of Medical Sciences (SVIMS) in Tirupati, where a relative works as an anesthesia technician. The trip cost 600 rupees (about $9) for each leg of the bus journey. As reported by The Economic Times in 2012, 60 percent of rural India lives on less than 35 rupees daily (about 50 cents).

SVIMS, a regional super-specialty hospital managed by the Tirupati Tirumala Devasthanams (which handles the trust of the Sri Venkateswara Temple in Tirupati), serves patients from all over India. SVIMS’ annual report demonstrates that there were about half of a million outpatient visits and about quarter million inpatient visits in 2014.

Kotaiah’s family is one of hundreds who flock to SVIMS daily for its charitable spirit and high quality of care. However, the astonishingly large volume of patients, emergencies and social barriers can cause some cases to temporarily veer off course.

When Gnanakumari was admitted on April 7, 2015, she was screened and sent to the outpatient endocrinology department. The endocrinologist diagnosed her with Cushing’s syndrome, an illness caused by an above-normal presence of cortisol in the body. In addition to weight gain, Cushing’s syndrome can be responsible for depression and anxiety, bone weakness, increased risk of infection, and a host of other symptoms that can make daily living difficult.

Further consultation revealed that Gnanakumari’s elevated cortisol was due to a tumor in her pituitary gland; she would need surgery to excise the tumor to return to normal. And surgery is expensive. Without a payment plan, Kotaiah would have had to sell his farmland for his daughter’s treatment or borrow funds from friends.

Kotaiah and his wife found out about "the Pranadana Scheme," a program at SVIMS to provide free medical care to the poor, when Gnanakumari was first admitted. Kotaiah recalls, “My relative said that Gnanakumari would be taken care of here.” Kotaiah obtained his family’s White Ration Card, a document indicating that his family was officially below the Indian poverty line, and Gnanakumari’s surgery was approved for the Pranadana Scheme coverage. The family was asked to come back at another date for the surgery.

When Gnanakumari’s family returned for the surgery, they were told that the surgery would be pushed back.

Nagadivya (an anaesthesiology resident and temporary translator for the family) and Kotaiah began a rapid exchange in Telugu. Gnanakumari’s surgery would be delayed yet again, but the family was insistent on staying until her procedure had been completed. When asked why the surgery had to be pushed back once more, the nurse replied that Gnanakumari had recently acquired a bacterial nasal infection. Nagavidya explained that the presence of such an infection could lead to complications post-surgery. The delay would be in Gnanakumari’s best interest. Although SVIMS staff generally takes the time to help patients understand their decision process, this isn’t necessarily the norm for other regional hospitals when dealing with impoverished patients.

If the current delays were medically necessary, why was Gnanakumari rescheduled for surgery so many times? Nagavidya says that delays in surgery could be caused by emergency cases that needed immediate attention in the neurosurgery department. Because Gnanakumari’s case was considered elective, the extensive screening process introduces quite a bit of variability.

After patients submit their Pranadana Scheme application and receive approval, their cases are “graded” on a scale based on severity, income level, and other sociological parameters to determine priority of care. On the last Thursday of each month, screening meetings are held to review and approve procedures. Patients are given tentative admission slots, and until then, must wait. Each selection meeting may include as many as 200 candidates per session. Managing this many cases can result in decisions that can sometimes leave patients frustrated.

Gnanakumari’s aunt said that female relatives had to be present for her surgery, and they found it difficult to give up their other responsibilities. While the family was very satisfied with many aspects of their experience at SVIMS, including the food and facilities, time was a luxury they couldn’t afford. Kotaiah joined in, saying ”I’ve locked the family home for 22 days. I will open it once the surgery is complete.”

According to Dr. B.C.M Prasad, dean of SVIMS and head of the neurosurgery department, Gnanakumari's surgery was performed on August 8 and there were no complications. During her most recent followup, Gnanakumari reported feeling better and had lost 15 kg.

SVIMS’ Pranadana Scheme opens doors for many of its patients by way of lifesaving treatment, even if it takes time for some of these doors to open.