What Happens When a Rural Hospital Can't Afford the Basics?
Imagine being in the middle of surgery when your equipment suddenly shuts down. Or discovering a cockroach crawling through the operating room during a procedure.
For Dr. Manu Kaushik, these weren't hypothetical situations.
In this episode of The Rural American Surgeon, Dr. Randy Lehman talks with Dr. Kaushik about the realities of practicing surgery in a struggling rural hospital in Alabama, where outdated equipment, missing supplies, and limited staffing created challenges most surgeons would find hard to imagine.
From purchasing his own surgical instruments to taking responsibility for operating room inventory and staff readiness, Dr. Kaushik explains why being a rural surgeon often means doing far more than operating.
He also shares a devastating experience involving an 18-year-old gunshot victim that exposed serious gaps in emergency preparedness and motivated him to improve his hospital's trauma response.
This conversation offers a firsthand look at the challenges rural surgeons face, the responsibilities they take on, and the difference one surgeon can make in a community.
Key Takeaways
00:00 A Rural Trauma Emergency
01:20 Rural Surgery Culture Shock
02:04 When the OR Goes Dark
03:09 Finding a Roach in the OR
04:13 Working With Limited Equipment
05:45 Why Rural Surgeons Must Lead
06:44 Buying Your Own Instruments
09:49 Financial Strain in Rural Hospitals
12:42 How Surgeons Change Communities
15:18 An 18-Year-Old Gunshot Wound
16:14 Operating Without the Right Trauma Tools
17:47 Losing a Salvageable Patient
18:05 Turning a Bad Outcome Into Better Systems
18:24 Rural Trauma Team Development
19:13 Stop the Bleed and Staff Training
22:13 The Broader Impact of a Rural Surgeon
Resources Mentioned
American College of Surgeons
Rural Trauma Team Development Course
https://www.facs.org/quality-programs/trauma/education/rttdc/
Stop the Bleed
UAB Medicine
Episode Transcript
Dr. Randy Lehman (00:43):
Welcome to the Rural American Surgeon. I'm your host, Dr. Randy Lehman, a general surgeon from Indiana. This show is tailored around the nuts and bolts of rural general surgery practice. You'll find topics such as practical surgical tips, rural lifestyle, finance, training, practice models, and more. We have a segment called "Classic Rural Surgery Stories," where you'll get a feel for how practice in the country differs from the city. If rural surgery is your passion, this show is for you. So, now that the ChloraPrep has dried, let's make our incision. Do you have a story your urban counterpart just wouldn't believe?
Dr. Manu Kaushik (01:23):
I have a few. Let's see how many I can actually share. So, so I think when I went down to the critical access hospital, I did get a little bit of a cultural shock. You know, looking at the hospital and the operating room, right? The hospital room was just, you know, bare bones. There was equipment which were the same forceps being used in 1990. Laparoscopic instruments were from 2001. They're all functional, don't get me wrong, but they were not as good. Like you know, things we got trained on were not there, so that was a big adjustment.
Dr. Manu Kaushik (01:56):
And especially when you come from residency, you know, you're a chief resident who's got a junior resident, you've got a medical student and an attending looking over your shoulder, you're able to operate, and now you just have a scrub tech and that's it. You have to figure out your retraction, even for a simple operation, right? Like, "Oh, I can't use two Richardsons because I only have one person with me." So switching to a Weitlaner and stuff like that. So that was interesting for me. The interesting things I saw: number one, doing a lap chole, you're dissecting the critical view, and the system shuts down. The lights are off. The insufflation's off. You're like, "What the hell's going on?"
Dr. Manu Kaushik (02:31):
Yeah, that happened a few times. So one of my partners used to go down there. This happened to him during an appendectomy. He was a very prolific surgeon, well known in the country, and he had to convert to an open appendectomy, which he did it, no problem, but it's such a bad feeling when you're doing it for like a 20-year-old. You have everything exposed. You're about to fire the stapler, and boom, everything shuts down. So that was one. Number two, the story which I think no one believes me, which I think I told you. Doing a lap chole, and then you see something crawl across the abdomen. That happened, and it was a roach.
Dr. Randy Lehman (03:07):
Oh man! Oh no!
Dr. Manu Kaushik (03:09):
So thank God I was laparoscopic, and I was able to. I was almost done with the operation, but that's when I went on, you know, witch hunt. I was like,"Why did this happen? This is impossible. I can never imagine." Because you know, the OR is like the most sacred place in the hospital. Right. And there's a bug. I'm like,"Okay, this is not right." So I closed the OR. Nobody was happy about it, but you know, if it was me or my family, you will not do that. And patients are a family. You cannot operate. So I actually went on a witch hunt and I found some open drains here and there. I found some problem with the autoclave.
Dr. Manu Kaushik (03:45):
I had to shut that down. Retire one autoclave. Get the company in. Seal some doors with the OR staff, work with them. I had to buy bug repellents, those ultrasonic ones, install them in every operating room, get an exterminator, get all the ORs clean. That took like a good three weeks. We were not operating. Since then, we never had a bug problem, but this happened. And, you know, for me, the problem was coming from the bigger hospital with all the resources. I had never heard of this happening, and my staff was just laughing. They're like, "Oh, that's funny." You know, so that was a big culture shock to me.
Dr. Manu Kaushik (04:22):
Another thing which happened to me was I was doing a gallbladder once, and the suction tubing fell down from the scrub tech's hand, and the scrub tech said, "Oh, that fell down." I said, "Okay, we'll use another one." That was the last tube in the hospital, and I'm already insufflated. I started my dissection. So I had to re-sterilize that tube, which was a very interesting process. Like I scrubbed out, wore sterile gloves, cleaned it with alcohol, Betadine, cleaned it again with alcohol, and then I wrapped Ioban around the tube and used that to finish the operation. So that was an interesting situation I was in. And then I think we've discussed this before about me buying instruments.
Dr. Manu Kaushik (05:03):
That was yeah.
Dr. Randy Lehman (05:04):
That's the main reason I was like when I heard this story, I said you got to come on the show and talk about this. Yeah, because and and everything what you were just talking about is also this this ownership of it that basically what you. You're bringing something in there. It's even just culture and leadership. It seems to you like a simple, um, you have to do. You are even saying you have to do this. Actually, no, you don't have to do that. Like some people would come in and not do it.
Dr. Randy Lehman (05:31):
But because of who you are and the type of person that it takes to get through general surgery residency, which is who I think most general surgeons are, they're going to come in and just naturally they're going to say things like that. Like you just have to do this. You can't. It's unacceptable.
Dr. Manu Kaushik (05:44):
It's unacceptable. And the problem is you can raise your hand and say,"Oh, I'm not going to work here anymore," and leave. You know. But but that doesn't solve the problem. And people people like us, especially general surgeons, we are problem solvers. You know, we have to find a solution, get the patient through this. So I think I think when working in a critical access hospital, what I learned was you have to be like a 3D surgeon. You have to be so multidimensional. Your job is not just not just to operate. Like you said, you have to be the leader. You have to guide the OR staff. Like. At the end of the day, I'm the one who's signing the anesthesia sheets too.
Dr. Manu Kaushik (06:16):
We don't have MD anesthesiologists, right? We have CRNAs who are fantastic, right? But at the end of the day, there's so much more responsibility as compared to being in the university setup. Whether you are defended by so many layers, you're protected. There's so many. There's a manager or in charge of everything, you know, in the operating room. But over there, it's just you. I had to do my own inventory, make sure that. We have all the meshes, we have all the clips. I would do it myself with the scrub tech, and that just adds on more work on your plate. But if you don't do that, you cannot function sometimes. So the instrument thing you brought up, yeah, it's a funny story.
Dr. Manu Kaushik (06:51):
So I typically do a gallbladder with a hook cautery, like most people. I know some people use the LigaSure, some people use scissors. We didn't have hot scissors, so I used to use a hook cautery, which I'm used to.
Dr. Randy Lehman (07:01):
Yeah.
Dr. Manu Kaushik (07:01):
One fine morning, I had three gallbladders booked on some other case, and I'm told we have no more hook cauteries because they used to have these disposable ones, which I never liked because it turns out to be more expensive using those. And they said,"You don't have a hook cautery." I said,"What do you mean you don't have hook cautery?" They said,"We just don't have it." I said,"Okay, great." Nobody gave me a heads up. Now they have three patients. I got through the cases with the LigaSure, which is not my personal preference doing these operations. But then I went to the management. I said,"Hey, this is the problem." And then the management tells me,"Well, we're having a financial issue.
Dr. Manu Kaushik (07:33):
We are on back order, this and that, you know. And as a surgeon, you're like, "Well, I've got ten more patients who need this operation in the next few weeks. What do I do?" They said, "Well, we can cancel the operation, but we do need the revenue." So I actually went to ACS the next week, you know, for my FACS or something, and then I met some vendors over there and ended up buying my own hook cauteries and brought them and used them in the operating room. They still have them. It's awesome. Yeah, I use the reusable ones, you know, which I think they should have from the get-go, the universal ones.
Dr. Manu Kaushik (08:07):
And then I called that vendor and he supplied me one more by mail, and that's how we continued doing that. I even had to buy my own, you know, Metzenbaums, my own DeBakeys because the ones they had were not sharp, and the hospital terminated the contract with the sharpening company because of financial issues. So I think people don't realize, especially in the urban setting, that a rural surgeon has to go through so much to get through some basic operations sometimes, which you won't even think about being in the city or in a big university hospital. That's what I tell the residents here too. I mean, you know, everyone is so spoiled.
Dr. Manu Kaushik (08:43):
Like, you know, you give them a 3-0 silk to do a Lembert suture, they do one, pop the needle off, get a new suture in. I used to do three stitches or four stitches with that because you have to save. And I think it makes you better. I personally felt my three years in the rural community made me a better surgeon, not just technically, but I think emotionally and mentally. I think much more when I'm in the operating room than I used to think as a resident. You know, like I need to know, like, okay, what instruments do we have? Why am I using this? Why am I using that? I became more economical in my technique and
Dr. Manu Kaushik (09:17):
In my usage of instruments, so how much did you pay for the hook cautery? Hundred and ten dollars. I still haven't got them back. I don't expect that, but it was funny. I actually brought it up with the management and said, you know, just saying, I bought them. We're covered. Don't worry about this problem no more, and they were happy with it. So.
Dr. Randy Lehman (09:34):
Yeah, so was there? I've heard about a honeymoon period where they'll buy you things. My hospitals are that I'm working in. They do not seem to be in as dire financial straits as what you're describing. None of them.
Dr. Manu Kaushik (09:49):
Yeah, so I think Alabama is a special place too. I think down in the South, I think we have the famous Black Belt, like they say, where we have a lot of rural population, and the place I was working at, you know, I think 23% of people are below the poverty line in that county. So it's a very poor community, and I actually looked up this data. I was doing some study, and their per capita income is 28,000 on average, compared to, I think, 43,000 in the United States. And almost 17% of people don't have a high school diploma. So overall, the community as such is very poor.
Dr. Manu Kaushik (10:26):
And the hospital not having a surgeon for many years, and with the neighboring hospital shutting down, is a big financial crisis. So what we are trying to do at UAB, especially my superiors, they're trying to partner with these hospitals to salvage these hospitals and improve rural surgery care. And, I mean, through a great program, that is, I think, in my opinion, the permanent solution for this problem: having more rural training programs. I don't know how that's going to happen. We've been talking about it over here to, you know, meet this need because we have multiple hospitals in a similar situation with the financial restraints, and they're really struggling.
Dr. Manu Kaushik (11:05):
We've had moments where they had to cut out the cable TV from the patient room. They didn't have enough money to take out the trash, stuff like that, which you never imagined being in a first-world country. It's still happening in the you know rural community. And you know, a lot of data shows that almost 60 million people are in these communities, and we're just running out of general surgeons because no one wants to do general surgery anymore. Right.
Dr. Randy Lehman (11:27):
Yeah. Well, the other thing that I think is when you come in as a general surgeon, it's kind of like what I was saying of managing up just by being there because you're everybody. This is my belief. Okay. Every human being has equal worth because they are a human being. Okay, but they're also not the same, right? And so you can manage up just by being different, not being the same, being different from them in terms of your perspective about what you think is acceptable, and just by existing there, it rubs off on the people around you. And and that's one thing about you know keeping your OR your sterilization.
Dr. Randy Lehman (12:12):
I mean I know I've been to Haiti and like their their concept of sterilization is a lot different. And and then uh what you're doing even just in the town as a whole that I think can happen like could could all incomes raise because. You know, Dr. Kaushik's in town, and his kids his kids go to town with us, and we see a different way, and we see how education is valuable, and then maybe we you know I don't know.
Dr. Manu Kaushik (12:42):
I think you bring up a very important point. I think as general surgeons we can make a big difference in a community, not just operating and taking care of pathology. I think, like you said, the whole mindset. I mean, the city feels comforted in the fact there is a surgeon to take care of them. I think that's the big trust factor over there. And secondly, like you said, with your individual force and your mindset, you can change the mindset of the whole hospital. I mean, that hospital never thought they would do laparoscopic colectomies. We ended up doing them, you know, and then that changes their mindset. Now the next person who goes there might be an expectation.
Dr. Randy Lehman (13:19):
Yeah, yeah.
Dr. Manu Kaushik (13:20):
Like, okay, you're already doing lap colectomies. Why cannot we do this? Why cannot we do that? You know, cholangiograms, for example. I was doing cholangiograms down there. And when I came to the university, we were doing much fewer cholangiograms than down there because we've got ERCP right here. So those things, I think, rural surgery, for the technical aspect of surgery, pushes you to get better because you have no choice. You have to do what you have to do with less. But also, I think the difference you can make to the community is just invaluable. I think the ACS website said that a general surgeon in a rural community can generate close to 26 jobs.
Dr. Randy Lehman (13:57):
Yeah, that's the number that I've heard as well.
Dr. Manu Kaushik (14:00):
So yeah, so it's incredible. I think there's so much we carry so much of positive power with us. If we use it the right way, we can make a huge difference in these communities.
Dr. Randy Lehman (14:09):
Right, and it's the opposite of the brain drain. A hundred percent, which is where the best and the brightest leave the town because they go work in the city, and then it's like just a self-perpetuating thing.
Dr. Manu Kaushik (14:20):
I think I think that's that's what I think that's the immaturity in the mindset. I think. When I was a junior resident, you know, I wanted to be a thoracic surgeon, period. Nothing else would do. You know, I would just be a thoracic surgeon. I want to wear my headlight, be in the chest, do the big stuff. But you know, as you mature as a resident, your mindset changes. And I think in the three years I was down there, I matured as a person because I realized it doesn't matter what I want to do. What matters is, I mean, you should be happy. But you have to identify one problem in life and just work towards it.
Dr. Manu Kaushik (14:52):
Be it rural surgery, be it thoracic surgery. You see a need, and if you're fitting in the puzzle, that's all that matters. You know, that's that's how I look at it.
Dr. Randy Lehman (14:59):
Yeah, progress.
Dr. Manu Kaushik (15:01):
Progress, yeah. I mean, if you're making a positive impact in something in life that's big, and as surgeons, we can make so much of difference. Like, for example, I know it's part of the segment of your show. In terms of the losses and how you recover from them and make a positive impact, I have a small story to share. You know, I was in the office and I was about to leave back for Birmingham, and then I get a call. There's a gunshot wound in the ER. That hospital, oh, bad. I get a call from the CEO saying,"Oh, can you just show up to the ER just to show your face?" So we said there was a surgeon involved.
Dr. Manu Kaushik (15:34):
This kid is almost dying. I said, "Okay, where was the kid shot?" They have no idea. The guy calling me does not know. So I quickly drive two minutes. I get there. Eighteen-year-old gunshot wound, entry wound with no exit, right here, the axilla. And they're coding him actively. So, terrible situation. And I ask, "When did you start coding him?" They said, "Two minutes." I mean, the kid needs an ED thoracotomy to recover, you know. And a few months ago, I had trained the ER staff that, you know, if this situation happened, this is our chest tray. I made them buy one rib spreader for the hospital just for a situation like this. And guess what?
Dr. Manu Kaushik (16:13):
No one knew where the chest set was. They could not find it. So, so I had to do a thoracotomy with just a scalpel in my hand, which was the most terrible experience I went through. And. When you sometimes when you start, you know this might not end well, but also you cannot let an 18-year-old kid just die in front of you without doing anything. So, like I did a, you know, left side thoracotomy, got in, no clamps, used the nurse's hand to cross clamp the aorta, which was terrible, and then opened the pericardium, got a little bit of blood out, did a clamshell on the other side. Maybe that was stupid of me.
Dr. Randy Lehman (16:47):
But the injury was on the left or the right side?
Dr. Manu Kaushik (16:50):
The injury was, sorry, injury was on the right side.
Dr. Randy Lehman (16:53):
Okay.
Dr. Manu Kaushik (16:53):
Injury was on the upper lobe of the right lung, which could have been was salvageable at a big center. Now the problem was it got into the right side. The heart was almost empty because the hospital only had two units of blood.
Dr. Randy Lehman (17:03):
Right.
Dr. Manu Kaushik (17:04):
And they had not given that blood because the patient was not crossmatched. So that's just... Oh my. Yeah, exactly. And it was a lost battle to begin with, but, you know, I found the injury. And interestingly, this kid was shot 30 minutes before being brought to the hospital. He was shot. He was talking. He was awake. He was probably just bleeding out from his lung. And they were supposed to bring him here with an ambulance and fly him out to the trauma center because they have a helipad, and he coded right on the helipad. So, salvageable injury, right? It's just terrible. And the kid died, which was unfortunate.
Dr. Manu Kaushik (17:38):
If he was at in Birmingham or a big city, he was in Indianapolis, he would have been okay. That would have would have saved him.
Dr. Randy Lehman (17:44):
I mean, just a massive transfusion protocol alone would have saved him.
Dr. Manu Kaushik (17:47):
Would have given him time, right? And the problem is, this kid, I lost this kid. I mean, and then I have to go talk to the family. Obviously, take the ownership. This happened. We tried our best. It made me feel terrible as a surgeon that you know that. I was not. I was upset about the outcome, but the outcome was pretty much obvious. But the way we were not able to do the right thing for the patient was the most frustrating thing.
Dr. Randy Lehman (18:10):
Yeah.
Dr. Manu Kaushik (18:10):
And that trauma really got to me, that trauma case. And I started trying to train the ER staff, do mock drills, get them prepared for, you know, doing a cric, ED thoracotomy, things where we can temporize the patient. So we did a few of those, and actually, I was not aware the ACS does have a Rural Trauma Team Development Course for centers. So I reached out to the ACS, and that's what I would recommend some rural surgeons doing in there by themselves. The closest Level I trauma center, if they're working with the ACS, they can actually come down to the center with the ER team and everyone, and they can look at the resources they have and actually train the staff for
Dr. Manu Kaushik (18:50):
Level I, Level II traumas, and prepare them how to use the existing resources and package the patient and get them out safely. So we're trying to do that for that community. Our trauma team at UAB has been helpful, and we're going to do that hopefully soon. But that's one resource I had no idea about: how we can help ourselves as rural surgeons and improve, you know, the environment we are in. The second thing I found useful was teaching Stop the Bleed. I've had a case where someone had a radial artery transection and was just laying in the ER and bleeding with no tourniquet. It was terrible, and OR was not available.
Dr. Manu Kaushik (19:23):
We had to, like, get the radial artery in the ER, which was fine. He did fine. The guy was okay. Thankfully, it was not dominant. And again, the ER staff did not know to put a tourniquet on the patient, which is so basic. And then we're trying to do Stop the Bleed courses over there, teach the schools over there. So, long story short, I think what we can bring as surgeons to these communities can be invaluable, even if it saves one life, you know, in the future. Because all these things about school shootings really scare me, and I feel like if all these schools get Stop the Bleed and stuff, maybe the kids can help each other if that happens ever. So.
Dr. Manu Kaushik (20:00):
Yeah, sorry I went off topic over there.
Dr. Randy Lehman (20:01):
No, that's beautiful, and it actually kind of dovetails into the last segment of the show: resources for the busy rural surgeons. So you've just said a couple, and then I was—that's different than the Red Book, right? The ACS Red Book.
Dr. Manu Kaushik (20:14):
Yeah, it is. I think so. At ACS, for free, you can do the stuff that you can become a trainer for Stop the Bleed, and then you can actually organize Stop the Bleed courses for your community. It just needs a few resources, which I think the hospitals can help with, and I think that can make a big impact. Training the EMTs. Sometimes even the EMTs don't do the right thing in the rural communities, which I have seen a few times. I think training the EMTs, the high schools, the hospital staff, every nurse. If you have a post-op patient bleeding, at least they can put pressure on it, you know, till you arrive.
Dr. Manu Kaushik (20:47):
And the Rural Trauma Team Development Course, if you just look it up on the ACS website, it guides you how to navigate that. So.
Dr. Randy Lehman (20:56):
Yeah, it's crazy how healthcare providers don't always understand the concept of, like, how to stop. We had a patient. This makes me think of a story, a little nasty story. Maybe I shouldn't, but whatever. I'll say it. We I had a patient. I was at ICU as an intern. And they had wound care service sort of developed and turned into, you know, nurse practitioner and debridement OR. That's kind of the the way that it ended up. Well, they had this sacral wound thing that it was like a, you know, I don't know, 45 minute case, you know, with like over a liter of blood loss and everything for the sacral wound debridement.
Dr. Randy Lehman (21:34):
And patient comes up and it ends up hypotensive, so gets transferred to the ICU after this case. And I'm up there as an intern, just kind of like sort of perplexed. But I remember we had to give multiple units of blood, and I was the one presenting on the patient in the morning to the staff. And it's like six o'clock in the morning, and talking about, well, this this time this is the vitals, and then we gave this transfusion and give saline, and and here's where we ended up. And he just like was looking at his paper. He looks up at me and he goes,"Well, boys, looks like you got a little experience resuscitating hemorrhagic shock." And we moved on.
Dr. Randy Lehman (22:12):
Stop the Bleed, man.
Dr. Manu Kaushik (22:14):
Yeah, Stop the Bleed. Exactly. But yeah, I mean, I would again repeat what you said. You know, you can bring so much as a general surgeon. And just when people see you, I mean, obviously everyone's different, but most people, when they see you showing interest, they get inspired to do something more than they're capable of. I think that really can uplift the whole community, not just a hospital. So yeah.
Dr. Randy Lehman (22:36):
Yes, that's very inspiring. I really appreciate your time. Thank you so much for coming on to the show today.
Dr. Manu Kaushik (22:42):
This was a great opportunity. Thank you so much.
Dr. Randy Lehman (22:45):
Yep, it's been our honor, and thank you to the listener for joining us on this episode of the Rural American Surgeon. We look forward to seeing you on the next episode. Don't forget to like, subscribe, and share this with all of the people that are in your circle that are interested in rural surgery. Thanks for being here. We'll see you on the next show.
Timecode:
00:43 Show Introduction and a Rural Surgery Story You Wouldn't Believe
01:23 Culture Shock at a Critical Access Hospital
01:56 Operating With Bare-Bones Staff and Equipment
02:31 Power Failure During Surgery and a Roach in the OR
03:09 Shutting Down the OR and Fixing the Problem
03:45 Rebuilding OR Safety and Sterilization Standards
04:22 When the Hospital Runs Out of Suction Tubing
05:04 Ownership and Leadership in Rural Surgery
05:44 Why a Rural Surgeon Has to Be Multidimensional
06:16 Inventory, Anesthesia, and Responsibility
06:51 Running Out of Hook Cautery
07:33 Buying His Own Surgical Instruments
08:43 How Rural Practice Made Him a Better Surgeon
09:49 The Financial Reality of Rural Alabama
10:26 UAB Partnerships and Rural Surgery Training
11:05 How Fragile Rural Hospitals Can Be
11:27 How One Surgeon Can Raise the Standard
12:42 Changing What a Rural Hospital Believes It Can Do
13:20 Doing More With Less and Creating Local Jobs
14:20 From Wanting Thoracic Surgery to Meeting a Need
15:01 The Gunshot Wound That Changed His Approach
15:34 An 18-Year-Old Gunshot Victim in the ER
16:13 Emergency Thoracotomy With Almost No Equipment
17:04 A Salvageable Injury Without Enough Blood
17:47 The Frustration of Losing a Patient to Resource Limits
18:10 Training the ER Team for Rural Trauma
18:50 Rural Trauma Team Development and Stop the Bleed
19:23 Teaching Tourniquet Use in the Community
20:01 Resources for the Busy Rural Surgeon
20:56 A Lesson in Hemorrhagic Shock
22:14 The Impact a Rural Surgeon Can Have
22:45 Closing
