Neurosurgery at Rajendra Institute of Medical Sciences, Ranchi; The Dark Horse of the East
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0028-3886.271265
Source of Support: None, Conflict of Interest: None
“Study the past if you would define the future”–Confucius
As per the recommendations of the Bhore Committee, the foundation stone of the All India Institute of Medical Sciences (AIIMS), New Delhi, was laid down in the 50s. Around the same time, Shri Krishna Singh, the first Chief Minister of an undivided Bihar, planned of giving shape to his dream of a medical college in Ranchi. This college, he visioned, would bring similar facilities at AIIMS to the people of Bihar, at Ranchi (then the summer capital of Bihar). The portentous task of looking for suitable land for the hospital was done by Colonel Deewan Pitamber Nath, the Inspector General of Civil Hospitals. Building construction thus started on a 214-acre land in 1958 and the first MBBS batch took admission in 1960 in Ranchi Medical College, which was renamed Rajendra Medical College and Hospital (RMCH) in 1963 after the death of the first President of India, Dr. Rajendra Prasad. In the millennium year 2000, Ranchi became the capital of the newly formed state of Jharkhand, and in 2002 the college was again renamed to the current Rajendra Institute of Medical Sciences (RIMS). Presently, there are 150 undergraduates and 195 postgraduate admissions undertaken annually. Today, RIMS is a 1500-bedded multispecialty hospital staffed with 276 doctors, 412 postgraduates, 452 nurses, 381 nursing students, 151 non-nursing paramedics, and 488 other staff [Figure 1].
The birth of the Department of Neurosurgery also dates back to 1960 when it was started by Dr. Risheshwar Prasad at Sadar Hospital, Ranchi. Later in 1967, the department was shifted to erstwhile RMCH and present-day RIMS.
“When building a strong team, you need a strong leader.”
Dr. Risheshwar Prasad, then a young lecturer in Orthopaedics at Darbhanga Medical College and Hospital, had opted for training in Neurosurgery in the United Kingdom in 1958. It is said that his maternal uncle, the late Devika Prasad who was once a member of the Viceroy's Council, suffered a head injury and was ultimately treated by Harvey Cushing. This had impressed and inspired Dr. Risheshwar as a medical student to pursue a career in neurosurgery. He completed his training at Royal Infirmary, Manchester, under Sir Geoffrey Jefferson and Mr. R.T. Johnson. He returned to India in 1960 and was posted as a special officer in Neurosurgery in Sadar Hospital, Ranchi. During these early years, Dr. Risheshwar in collaboration with Dr. Davis of the European Mental Hospital performed probably one of the first leucotomies in India. His early days of neurosurgical practice comprised mostly of head injury and spine problem management.
In 1962, the brilliant young physician Dr. Krishna Kant Sinha joined the Department of Medicine in the then Ranchi Medical College and Hospital. He had just returned after completing his MRCP and tenure as a neurology resident and registrar in various hospitals in the United Kingdom. Dr. Sinha had also had the honor of working with the famous Dr. Stanley Davidson and Dr. Donald Hunter, physicians of global renown and respect. This was a very crucial time for neurosciences practice in Bihar which had just been blessed with a neurologist and a neurosurgeon [Figure 2].
In 1967, Dr. Prasad, the head of the department, was instrumental in shifting the department from Sadar, Ranchi, to the erstwhile RMCH. The whole transfer process was performed in over just 2 days. He was assisted by Dr. N.P. Sinha and Dr. Gyansheela Jaiswal.
Despite limited resources and inadequate funding, Dr. R. Prasad's vision, courage, determination, and selfless devotion transformed the department and gradually they began to manage the neurosurgical patients previously being treated by general surgeons. “Mr. Karma Oraon, the oldest operation theatre assistant (OT) recalled the work ethics of Dr Prasad who used to work day-in and day-out. The department was poorly manned but this never discouraged Dr. Prasad. There were no fixed working hours and everybody worked till late every day. As the operation theatre key used to be with me and I did not have a phone facility, I had strict instructions to be at home even after duty hours. If any operations needed to be done late night, [Dr. Prasad] would come pick me up or send an ambulance with a nurse who was generally borrowed from the ward rounds and the patient would be operated. His passion was contagious. He is rightly known as the Father of Neurosurgery in Bihar (and now Jharkhand).” Mr. Karma Oraon still works in the department today. He is the first OT technician and assistant of Dr. Prasad who earlier worked in the Dermatology Department and was transferred to Neurosurgery once Dr. Prasad established the department in RMCH. He is famously known in the institute as Karma Da (Da implies elder brother) and sometimes as Dadu (respectful term implying grandfather) and has worked in the department for more than 50 years now.
Dr. Hari Prakash Narayan was another stalwart who played a very important role in developing neurosurgical practice in Bihar. He came to Ranchi in 1964 and was appointed as the Deputy Superintendent of erstwhile RMCH. He understood that if neurosurgery was to gain ground, it had to be an integral part of the medical college and hospital. On a bright morning in March of 1967 while discussing and planning the future of RMCH over a cup of tea, Dr. Narayan persuaded Dr. Prasad who was also the Regional Director at that time to transfer the Department from Sadar Hospital to RMCH. Dr. Prasad agreed and passed an order to transfer the whole department with its entire staff to the medical college. Dr. Narayan then underwent training in neurosurgery for which he went to the United Kingdom and spent three and a half years at the Royal Infirmary Hospital, Manchester. Meanwhile, Dr. R. Prasad and Dr. N. P. Sinha took the department forward at RMCH.
Dr. Narayan returned to India in 1971 and joined RMCH. He was posted as medical officer on supernumerary duty in neurosurgery. The neurosurgery team was becoming stronger by the day. Some of the complicated brain and spine patients who used to be referred to high centers (most Christian Medical College, Vellore, and AIIMS, New Delhi) due to lack of manpower and infrastructure, were now being operated at RMCH, Ranchi. Now there was also a separate OT team. Dr. Narayan and Dr. Akhilesh worked with the Isotope Brain Scanner. The number of operations increased to around 60 per month but most of them were trauma and spine cases and only two to three brain tumors in a month. In 1973, Dr. B. Ramamurthy, Doyen of Neurosurgery in India, inspected the department and recommended the creation of posts and upgradation of the department, following which Dr. Prasad was designated as Professor. He retired in 1979 and Dr. Narayan became the head of the department. In 1983, the first head and neck computed tomography scan machine [Figure 3]a of Eastern India was installed at RMCH. Over time, there were the additions of an EEG and EMG machine, portable X-ray machine, an operating microscope [Figure 4], X-ray image intensifier, and ventilators for neurosurgery OTs [Figure 3]b. Patient numbers increased daily. In early 90s, Dr. C. B. Sahay, then a resident doctor in the department, started living in paying wards of the hospital so that the patients could be better attended. He also got an intercom phone running (at his own expenditure) between the neurosurgery ward and his room in the paying ward. Dr. H. P. Narayan retired in 1994 when Dr. Basant Kumar Singh became the head of the department.
Under the strong guidance of Dr. B. K. Singh and later Dr. C.B. Sinha, the department achieved new heights. With the good quality of work being done, the department was soon recognized and was regarded as an important referral center for neurosurgery in eastern India. After formation of the new state of Jharkhand in 2000, the first Chief Minister, Mr. Babulal Marandi on 15th August 2002 declared RMCH to be autonomous with the new name Rajendra Institute of Medical Sciences (RIMS). He intended to provide the facilities and infrastructure to develop the institute in the pattern of AIIMS, New Delhi. A special upgradation program and fund was announced for the development of neurosurgery department. The planning and execution of the upgradation finally started in 2004 for a neurosurgery OT and intensive care unit (ICU). In this period, two new OTs, a 10-bedded ICU, 10-bedded high-dependency unit (HDU), and 32-bedded observation ward were built and all these areas were planned for centralized air conditioning. A high-end operating microscope (Mueller R1000), ultrasonic aspirator (Sonoca 300), high-end anesthesia workstations, electric and pneumatic drills, good quality diathermy, ICU beds, and ventilators were procured. In May 2006, Dr. C. B. Sinha and Dr. Anil Kumar went to Germany for neuroendoscopy training with Dr. Gabb. Dr. C. B. Sinha also presented his work in World Federation of Neurosurgical Society (WFNS), New York, for which he was well-praised.
“A leader is one who knows the way, goes the way and shows the way.”
Dr. Anil Kumar, the man with the vision and the persona to bring it to reality, took over as the head of the department in 2006. He had completed his MCh from RMCH in 1990 and joined as Lecturer/Registrar (Neurosurgery) at RMCH in 1997. After 2006, under his able and bold guidance as the head of the department, the department underwent a huge transformation. Dr. Kumar along with Dr. C. B. Sinha was instrumental in formation of Jharkhand Neurosciences Society in 2008 under aegis of which the annual conference of Neurotrauma Society of India was organized in 2011 with Dr. Sanjay Kumar, then consultant Neurosurgeon, Apollo Hospital, Ranchi, as the Organizing Secretary. The vision of the society was to provide better neurosurgical services to the poor tribal patients of this area, who were mostly economically weak and being referred to higher centers, often opted to leave the outcome to destiny.
In 2006, the newly built ICU started functioning, while 2007 saw the commencement of neurosurgery twin OTs; and an ethylene oxide (EtO) sterilizer was installed. In 2008, the ICU was upgraded with the state-of-the-art high-end multipara monitors under the Pradhan Mantri Swasthaya Suraksha Yojana (PMSSY). In 2009, C-arm and plasma sterilizers were installed in the neurosurgery OT complex, and the number of patients being operated increased massively. The profile of the cases being done transformed from head-injury-centered to mostly cold cases, while head injuries were operated on mostly by junior faculty and postgraduates. In 2011, world-class Zeiss Pentero 900 was installed and Karl Storz endoscope set was procured. This was a new era of Neurosurgery not only in RIMS but also in Eastern India. RIMS became the first institute in India to have a Zeiss Pentero 900 microscope. Dr. Anil Kumar wanted that the patients who due to lack of adequate services, huge patient queues, lack of awareness, and poor financial status could not go to metropolitan cities for treatment be treated at RIMS. In 2010, the number of operations per day increased to four times when compared with before.
In the year 2017, a portable CT scan machine – the first in eastern India – was installed in the neurosurgery ICU, and since then it has been the guiding light in deciding the treatment plan and postoperative follow-up of patients of trauma, brain tumors, and other brain pathologies.
In 2018, the neurosurgery OT was further rebuilt and was equipped with high-end modular OT by Martin, Germany, with integration by Karl Storz [Figure 5]. A 3-D Karl Storz endoscope was also added to the paraphernalia.
Since its existence, the department has had to deal with two big issues – the first one being the tremendous load of patients and the second of the lack of departmental manpower. The department serves patients from Jharkhand, a major portion of Bengal, and a good part of Bihar, Odisha, and Chhattisgarh. At present with a strength of 14 which includes all faculties and postgraduates and a patient load of around 200, it is quite common for staff to spend most of their day in the hospital. The day starts with the routine cases which includes brain tumors and other associated pathologies or spinal cases and ends with emergency trauma cases with round-the-clock emergency services. All this requires an efficient and fully dedicated team. [Figure 6] shows the graphical representation of load of operated patients over the past 4 years.
With 110 beds and an average in-patient load of around 180, flooring of extra patients has always been a problem. Managing beds for the patients needing them the most is an everyday hurdle and the maintenance of strict asepsis is yet another problem, especially with pressure from politicians, but this has never stopped the team to work with their full potential. In fact, this has entailed upon them to work even harder, no matter what the situation, or how mere the resources. It all lies in the dedication of the entire team that RIMS is the first and the preferred option for neurosurgery in this part of the country.
Dr. Anil Kumar (Prof. and Head) passed MCh from RIMS in 1990. He is the Vice President, Association of Neuroscientists of Eastern India (ANEI), member of the National Committee for Traumatic Brain Injury guidelines in association with the American Association of Physicians of Indian origin (AAPI), and executive committee member of the Neurotrauma Society of India (NTSI). He has special interest in microneurosurgery and neuroendoscopy. He is an eminent teacher and a respected academician. He is a reviewer of many international journals and is on the editorial board of critical journals.
Dr. Chandra Bhushan Sahay (Prof.) passed MCh from RMCH in 1993; he has special interest in brain tumors, syringomyelia, Dandy–Walker malformation, and firearm injuries.
Dr. Thomas Justin Minz (Assoc. Prof) passed MCh from RIMS in 1990. He has special interest in spine surgery and various congenital spinal dysraphism. He takes special interest in teaching neuroanatomy and history of neurosurgery to postgraduate students.
Dr. Anand Prakash (Asso. Prof) passed MCh from RIMS in 2010. He has special interest in craniovertebral junction and skull base surgeries.
Dr. Gautam Dutta (Assistant Prof.) passed MCh from G.B. Pant hospital in 2018. He has special interest in endovascular approaches to vascular surgery.
Dr. Rohit Bharti (Assistant Prof.) passed MCh from Goa Medical College in 2018. He has special interest in skull base surgery.
Neurosurgery would be possible without selfless and dedicated support of an orchestrated OT team. Our department contains nine scrub nurses, nine technicians, and six other staff. With two new modular OTs and a dedicated team, the OT functions around the clock nearly every day.
The 10-bedded ICU is the most sophisticated part of the department with electronic motorized beds and high-end multipara monitors with facility to measure etCO2, a portable CT scan machine, a portable X-ray machine, a transport ventilator, an ABG machine, 10 ventilators, and a centralized monitoring system.
In 2017, the ICU received four intracranial pressure (ICP) monitors, which are crucial in patient management. Raised ICP commonly precedes clinical deterioration. ICP monitoring can thus warn the clinician of impending deterioration and provide time for remedial action to be taken before severe or irreversible damage has been takes place. All four techniques – ventricular catheter, parenchymal catheter, subdural, and epidural probes – are in common use especially in assessing the neurological status in paralysed ventilated patients and in those whom decision of surgery is debatable. This process is being performed bedside in neurosurgery ICU and is a very valuable addition to the department.
The HDU also has 10 beds. The HDU is well-equipped with the state-of-the-art electronic beds with multipara monitors and five portable monitors.
There is also a 32-bedded observation ward for operated stable patients and a 58-bedded general ward for stable patients or for routine cases awaiting operation which comprise mostly of brain tumors, spinal pathologies, and congenital malformations of spine and brain.
With increasing number of patients and good quality of work, the department was recognized and MCh Neurosurgery courses were started in the year 1980 with the permission to register one MCh student per year. Dr. Arun Kumar Agarwal was the first MCh from Bihar and Jharkhand. Today, he serves as the Professor and Head of the Department of Neurosurgery at Patna Medical College and Hospital, Patna, Bihar. Since then 27 residents have been trained in the department [Table 1].
Between 1980 and 1990, however, after the retirement of Dr. R. Prasad, there was a void with only Dr. H. P. Narayan as a teacher. The Bihar government took cognizance of the situation and two surgeons Dr. B. K. Singh and Dr. C. B. Sinha were appointed in the department as Assistant Professors. Later, they were registered for post-MS MCh course with special provision of Teacher's Quota in Ranchi University and were promoted to Associate professorship after the retirement of Dr. Narayan. During this period, the MCh course in neurosurgery was allowed for special provision of TRP (Trainee Reserve Post) for candidates who worked state goverment jobs and passed the entrance examination. These candidates were posted in the department with full salary during the MCh course. This came as an incentive as post-MS students had not previously joined the MCh course because the small stipend was not enough to meet the daily needs of the student.
After 1994, Drs. B. K. Singh and C. B. Sinha managed the department with one RSO (Resident Surgical Officer), Dr. C. B. Sahay. In 1997, Dr. Anil Kumar joined as lecturer. As the faculty strength increased, students started joining MCh Residency after a gap of years. All these circumstances jeopardized the development of the department for a few years on the academic front, but the attending neurosurgeons continued their selfless service to the poor and needy of the part of the country.
At present, there is one 6-year integrated course seat for MCh Neurosurgery. In the recent past, the department has been very active on the academic front as well and has produced more than 50 publications in renowned national and international journals over the past 4 years and multiple platform presentations in various conferences. The department organizes weekly seminars, case presentations, journal club, and mortality meet. Apart from these, there are weekly sessions on neurology, neuroanatomy, neuroradiology, and neuropathology to refresh knowledge of the basic neurosciences. The department also conducts skill improving cadaveric workshops on spinal instrumentation, neuroendoscopy, craniovertebral junction surgery, pituitary surgery, and so on. In 2013, the R Prasad endoscopic operative workshop and EEG workshop were also organized. On request of the National Board of Examinations, the department has conducted practical examination for DNB Neurosurgery course on various occasions. Enrolment for Ph. D. course in the department of two candidates was also done and Dr. Akhileshwar Prasad Singh and Dr. B. P. Sinha were awarded Ph.D. in due course for the same.
Other than academics and the busy work schedule, the department also organizes frequent outings and an annual gala picnic for all the members of the neurosurgery team.
The majority of patients admitted in neurosurgery department are those of trauma, mostly road traffic accidents. This has always been the case and the department has left no stone unturned in bringing awareness among the common people regarding road safety and has been an active participant in awareness programs in schools and road safety rallies.
The department recently completed its 50 years in April 2017 which was another milestone in the history of this institution. It was celebrated as MidANEICON and Neuro50 in conjunction with the mid-term conference of the Association of Neuroscientists of Eastern India. Prof. R Prasad memorial neurocritical care workshop was also organized with the participation of neurosurgeons and anaesthesiologists from around the globe. Also during the same time, the department's newly designed logo was unveiled by a fast friend of the department, Dr. Shankar P. Gopinath, Prof., Neurosurgery, Baylor College of Medicine, Houston, TX, USA. This logo was conceptualized by residents Dr. Viraat Harsh and Dr. Saurav K. Besra, wherein the Caduceus staff was replaced by the spine and the round head of the staff by brain [Figure 7].
Recently, the institute has also started a 100-bedded trauma center in RIMS and is functional with all facilities [Figure 8]. The department is gaining strength with every passing day and now consists of an enthusiastic team of experienced faculty and zealous residents [Figure 9].
We are also planning for the procurement of a neuronavigation system and gamma knife surgery suite. With the radiology department, there are meetings regarding development of a Neuro Cath-lab for aneurysm coiling and other endovascular surgeries.
The department is a jewel in the well-sculpted crown of the institute, a dark horse in the history of neurosciences in India. The members of the department strive hard to reach out to the people and provide them with the best available routine to freedom from their ailments. The department alleviates the needs and the debilitating by conferring the treatment aided by state-of-the-art technology.
Mr. Nitesh Kumar, neurosurgery research assistant, has helped the department in data collection and record maintenance of the ever-growing number of cases. We would like to thank him in helping us in writing this article. We would also like to convey our gratitude to Karma Da (Mr. Karma Oraon) for helping us on the facts of the history of the department.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]