On Nov 15, 2019, I went to Karachi for one of my periodic working visits to the SIUT. I stayed at the SIUT as they have some rooms for visitors ( mainly from out of the country).

Staying at the Institute gave me the allowed me to go in early in the morning and attend meetings and get started with rounds. Some evenings I would go home with Dr Rizvi for dinner and some evenings I would visit old friends. The weather was good. The good news is that despite the mosquitoes , I was able to avoid getting an attack of dengue fever.

In the morning the Gastroenterology and Hepatology Unit has a patient related conference where the entire faculty gets together to discuss either a didactic topic or a patient related therapeutic issues. This is a custom in most teaching hospitals and is diligently pursued at the SIUT as well. At 9 am the different teams fan out to do their daily work. The main activity is of course taking rounds in the GI wards. The ward team usually spends the days pursuing the various activities of the ward.

Mondays and Saturdays are Out Patient Clinic (OPD) days. They see 400-500 out patients on each of these days. An OPD at the SIUT is an experience like no other. For example, the Urology OPD, sees anywhere between 1400-1700 patients a day. No other facility in Pakistan is equipped to handle this kind of load. The patience with which the patients sit in the waiting area speaks volumes of the working style of the SIUT. No one is agitated even though patients have come from long distances. They know that no matter how long it takes, they will be seen and in their due turn. It illustrates that our people can be very disciplined once they are assured that nobody is going to cut in.

The OPDs are very organized. Despite not having electronic medical records, every patient has their old charts present. Labs are drawn immediately and an ultrasound done if needed. By the time the physician gets to the patient, essential evaluative work is done and quick decision is taken about future medical management. This is the only way such a large load of patients can be seen efficiently. The hallmark of this activity is that the OPD is not closed till the last patient is tended to. A physician from the western world quickly realizes that this medicine is different from the developed world, but necessarily not any less in effective.

5 days a week we did endoscopies. Complicated endoscopies are done on Mondays and Thursdays. These are usually endoscopic therapeutic procedures for diseases of the gall bladder and the pancreas. They are complicated and something I specialized in. Over the years I have been doing them along with the doctors there for the last ten years. Several of the physicians who trained with me have now joined the faculty and now work with us. Seeing them come along like this and handle cases from the city on their own is very gratifying.

It must be mentioned here that SIUT has unlimited number of patients as far as these complicated cases are concerned. The need in Karachi is so much, that they just have to start a service and the book is full within days. Clearly not what goes on in the West.

The unhappy aspect of all this is that we saw patients requiring complicated procedures referred in from almost every hospital in the city on a daily basis. These procedures require skill and a lot of expensive equipment. We would get patients from Indus and even AKU. Sometimes because the patient would run out of money and sometimes the hospital would exhaust their expertise at handling the clinical problem.

These procedures require a lot of ancillary equipment which is imported and hence it is quite expensive. I have established relationships with some companies in the US that make this equipment and they give me quite a supply each time I go to Karachi. In addition I was able toget a donation of three duodenal endoscopes which I carried with me. When all this is coupled with what SIUT purchases on a regular basis I must say that SIUT spends a lot of money on just endoscopic equipment. On some days we were placing 5-6 metal stents in the bile ducts. Each of these stents at least 1-2 lakh rupees ,not counting what it would be in terms of room and physician charges at another facility.

Therefore the quandary is how to deal with these patients. SIUT has limited resources and the administration has to decide how much to promote a certain subspecialty . The more they do the more the number of patients.

SIUT’s primary focus is urology and transplantation. But since liver transplantation is on their agenda for the last ten years, they have to have a fully functional Gastroenterology and Hepatology Unit. There are many problems to this end.

1. Funds: As mentioned above the whole enterprise including liver transplantation is very expensive. In the US, liver transplant cost 100,000 – 150,000 dollars each.
2. Faculty: It is very difficult for SIUT to retain good faculty. Dr Rizvi used his contacts to
   have some of the doctors trained in Singapore and Korea but after they came back and established themselves, the private hospitals, specially AKU made them offers they could not
   refuse
3. Space: Because of all that is going on, space is a premium. We are facing a road block as far as any physical expansion is concerned. A building right next to the main gate has been acquired and within the next two years it might be built into a hospital. But for now there are some road blocks being put up in the form of some tenants who are occupying the building even though it has been bought by the SIUT.

We are in the process of writing a proposal on how to totally revamp the Gastroenterology Unit. Once we have the proposal put together, we hope to start construction of a 3 operating room unit. Additionally we are looking to build a large pre and post op areas. This is going to be a large expenditure ( 10 million US). A couple of donors have agreed to step forward and help us realize this dream.

Besides this SIUT is spending a lot of money in getting electronic medical records. They are busy digitizing the patient data from the last many years and getting ready to go live in the next year or so. The basic software is being purchased from Shaukat Khanum at a substantial discount.

As I have mentioned earlier, SIUT spends a lot of money in training nurses, radiology and laboratory technicians. Several hundred young men and women graduate every year. This helps in human development and provides employment to hundreds of people.

SIUT was able to recruit Dr Farhat Moazzam from the AKU many years ago. She is now Professor of Bioethics. She has set up an internationally recognized Center for Bioethics which has been accredited by the WHO as the only one in the region. SIUT has invested a lot of money and human resources in this endeavor and it is clearly paying dividends.

Incidentally Dr Rizvi had some biliary colic and some gall stone impaction in the bile duct. I was able to make use of my time there and do a procedure on him under general anesthesia. I am happy to note that he has really improved symptomatically after this procedure. That was very gratifying for me.

The next visit has been put on hold for now because of the prevailing situation.

Tariq Shakoor MD.

 

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