Nepal: A Trip To Dhakalthok

As I mentioned in the first blog post, our group was fortunate in meeting with Peter, the founder of Tsering’s Fund at his hotel. We had arranged to meet him for dinner and when we arrived we saw a huge truck being loaded with rice, tents, tarpaulins and various items useful to a village in need. Peter said that they were leaving the following morning for the home village of his friend Raj. This village had been completely flattened by the earthquake and had suffered fatalities due to the damage.

Sara and I saw our chance to do something useful with our time, so we cheekily asked if we could tag along. Less than 5 minutes later we had a jeep and a driver sorted for 6am, so with half an hour before dinner we went shopping. We decided that in our roles as health professionals it was in our interests to do our best to promote good hygiene and cleanliness, so that was the focus of our shopping trip. We went to a tiny shop 5 minutes walk from the hotel and began our mission. The main items on our list were things like soap, shampoo and toothpaste so that the families could look after themselves. We wouldn’t have dreamt of going out to a village with just these supplies but tagging along with 3 tons of rice seemed more appropriate.

As a side note we heard stories of medical teams swooping in to remote villages with all sorts of medicines and dressings but with no food, and bearing in mind some of these villages had been unreachable for weeks, to have a truckload of bandages and antibiotics turn up when your village is starving, is next to useless.

A minor dilemma we had was about exactly what products would be both suitable and the best value. Luckily it’s common for shampoo to be sold in sachets in Nepal, so that was perfect. Bars of soap were individually wrapped, toothbrushes sealed, it was excellent. But then the issue of sanitary towels raised its head. Disposable towels run out and create waste. Reusable products like washable towels need to be properly cleaned to minimise the risk of infection. Unfortunately we had to go with the wasteful option.

As we loaded our bags up and explained why we were emptying their shop, the owners suddenly became really excited and started throwing in donations of their own, as well as really decent discounts on the items we were buying. It was so incredible to watch them scurry through the shelves and then dig out a bag of hair clips or some other luxury item that they wanted the girls of the village to have.

With 5 full bags of sanitary goods, water bottles, rope, reels of hose, books, pencils and of course, toys, we dragged ourselves back to Peter’s hotel for dinner. I think they were quite surprised at how much stuff we managed to accumulate in less than an hour, but of course we were annoyed that we hadn’t thought of tagging along sooner, because we could have spent a whole day buying even more!

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Shopping!

Soap, shampoo, sanitary towels, pencils, paper, colouring books, toothbrushes, toothpaste, hair bands and clips, water bottles, hose reels, scrubbing brushes, balloons and bouncy balls.

Soap, shampoo, sanitary towels, pencils, paper, colouring books, toothbrushes, toothpaste, hair bands and clips, water bottles, hose reels, scrubbing brushes, balloons and bouncy balls.

We spent dinner listening to the amazing stories that Peter’s team had to tell; Eric’s adventures rafting in Tibet, Pem Dorjee’s life as a Sherpa (he got married on Everest!) and Peter’s never ending efforts to improve the lives of Nepalese children.

Inspired and excited, we all retired early for the 5am start the next morning.

The drive to the village was long and uncomfortable but at the same time gorgeous and breathtaking. We weaved our way across the mountain roads, and across what used to be roads before the quakes hit. At some points there were piles of rubble 2m deep where landslides had covered the road, which we had no choice but to drive over. There were times when I was doubtful we’d get through, but then I remembered that the truck had literally just steamed on ahead, so of course we’d make it.

The convoy on our way to Sindupalchowk

The convoy on our way to Sindupalchowk

Obligatory "looking at the map on the car bonnet" photo

Obligatory “looking at the map on the car bonnet” photo

We arrived at the village at about 9am, and a crowd began to form around the truck. Peter (a dentist) began handing out sweets to the kids and got completely mobbed. We walked around the village, shocked at the utter devastation. Everyone here had suffered loss, many were lucky and had only lost their homes and their possessions, others lost cattle and livelihoods, some lost wives, husbands, mothers, fathers and children.

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Someone lived here once

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The view from the village was breathtaking, but the devastation was everywhere.

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Every family was affected by the earthquakes.

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This crack in the ground appeared during the earthquake, one woman told us that scalding water shot out of the ground and burned her arm.

One infant was pulled from the rubble, alive, but something about his eyes hinted at a possible neurological injury. It was those like him, who survived against the odds, that kept the others strong and determined to rebuild. The road to the village had only just been cleared, so outside aid hadn’t yet reached the people there. The village’s school was completely destroyed but materials were salvageable, and tents were provided as a temporary measure. The biggest house, a two storey townhouse sorta building was still standing but completely unsafe.

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This infant was pulled alive from the rubble after being trapped for several hours.

We were shown around the village, led over piles of rubble where houses once stood, and told stories of loss and heartbreak. Then we got the balloons from the car. When the kids realised we had goodies we got mobbed. They were already eager to play around and loved having their pictures taken, but when they were given the toys, the atmosphere became electric. Balloons inflating as far as the eye can see, balls flying through the air, smiling faces… It was incredible.

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The kids loved having their photos taken

The kids loved having their photos taken

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Who knew an Angry Birds colouring book could bring such joy?

After cheering the kids up for a while, we asked the women to line up to receive their (somewhat less exciting) goodies. The queue stretched back forever, but we got through it quickly, filling open hands with shampoo sachets, bars of soap, sanitary towels, hair bands, toothbrushes and toothpaste.

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Then we stood aside while the guys with the truck got to work. 3 tons of rice and ton of lentils, distributed to each family. Not long after, I looked past the truck and saw a line of villagers carrying their rice to their makeshift homes. It was quite a sight.

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3 tons of rice!

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Family names were called, rice was distributed, then the next came forward.

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The entire village came out to receive food and aid.

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The rice was carried home.

Then came the awkward bit- the famous Nepali hospitality. These people who were poor before their homes were destroyed insisted on cooking us all lunch. We couldn’t say no because that would be rude, but taking food from those with nothing was excruciating. And really really tasty.

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The truck was empty so the kids piled in.

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The TASTIEST dal bhat ever. Also the guiltiest.

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It’s kind of natural to smile for a photo, except when you’ve lost everything.

We left shortly after lunch, cramming ourselves back into the Jeep for the long bumpy journey back to Kathmandu. When we got back to Peter’s hotel, we all sat outside and talked about the day. The two photographers Wes and Eric looked through their cameras and showed us their favourites, competing against each other for the best photo of the day. Wes had been swamped by the kids, so his photos were mostly of bright colours and happy faces, while Eric walked around and spoke to the adults who had lost their homes, so his were more dramatic and evocative. Both sets of pictures showed our experiences perfectly, and captured the emotions vividly.

While we looked through the photos, black clouds crept above us and thunder rumbled menacingly, while flashes of lightning lit up the sky. We took that as our cue to put the expensive photographic equipment away and go our separate ways. I wanted to walk in the rain for a while, the events of the day had affected me and I wanted some time to process them. My colleague S didn’t fancy retiring immediately to the hotel, so we walked for a while around Boudhha, seeing how different the landscape was when the sun wasn’t shining. We observed a Buddhist ceremony in a tent outside Boudhanath, and then walked back towards our hotel, past one of the vast tent cities that had sprung up in a nearby park.

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Boudhanath Stupa

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These impromptu housing estates were genuinely astonishing, as they popped up in every open space, and the inhabitants didn’t fit one particular class or caste; they were all just people who had been made homeless by the earthquake. We saw a couple of teenagers sitting in a large tent playing Angry Birds on iPads, while next to them was a bit of tarpaulin draped over some bamboo housing about 8 adults and 5 children. The government had opened up public parks and spaces to allow people to put up tents, and even military grounds were covered in tarpaulins, but some of the more exclusive hotels had increased their security to prevent anyone from camping on their lawns and being an eyesore to the guests. This was even more shocking considering that some of the more “famous” aid agencies had booked rooms there for their staff and volunteers.

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The reality of life under canvas was even more stark when the rain started.

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Even roundabouts were covered in tents.

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Some could afford to buy tents from the trekking shops, others made do with tarpaulins.

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Tundikhel Park, a sacred and special ground became home for many.

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Even the slums were damaged when the earth shook.

We continued walking in the rain, enjoying the fact that we weren’t inhaling dust anymore (Kathmandu is a really dusty and polluted city at the best of times so when half of the buildings are in pieces, the dust is a real problem) and talking about what we wanted to do next. After about 2km we were both a bit tired and facing a long walk uphill when a car pulled over in front of us blocking our path. It’s a fairly safe city, but instantly my heart raced, wondering what was next. Tsering wound her window down and exclaimed “who do I see walking around in the storm?” and ushered us into her car. We gratefully accepted.

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Nepal: The Hospitals

So after my ranty overview, here’s some info on the hospitals I visited and my impressions of the medical care I witnessed.

Bearing in mind the rest of the team had already been to about 10 hospitals by the time I arrived, we were starting to run out of options!

The first hospital I visited was Patan Teaching Hospital, a large facility to the south of the city. The most striking scene was the sea of tents outside the building. Apparently the hospital had sustained some damage, but the main reason for relocating outside was due to fear of aftershocks, and people didn’t feel safe above the ground floor.

Tents in the courtyard, replacing damaged and unsafe areas of the hospital.

Tents in the courtyard, replacing damaged and unsafe areas of the hospital.

In the first few days after the initial quake the hospital, like most others, became very busy with mainly orthopaedic patients suffering from injuries to their extremities. An orthopaedic theatre, run by a combination of local staff and overseas volunteers, had been established outside in a tent. When I was told about this my first question was “Do you have a C-arm in there?!” Yes, but no lead. And really close to other tents and working environments. Luckily (!) due to the atmospheric temperature being in the 30s use of the C-arm was limited due to risk of overheating. But it was certainly a sight to behold!

A temporary orthopaedic theatre outside the hospital. With C-arm. In a tent.

A temporary orthopaedic theatre outside the hospital. With C-arm. In a tent.

Inside the building’s radiology department was a quite fancy DR unit (nicer kit than we’ve got at home!) but it wasn’t busy enough to warrant using both rooms. The CT scanner was fairly busy, but that was about it.

Newly installed radiological equipment.

Newly installed radiological equipment.

Patients were lined up in the ground floor corridor and outside in the tents. Ex-fixes and casts were the main repair strategy as nailings and ORIFs take too long and increase the risk of infection. Generally it seemed that more complicated injuries were less survivable although cardio-thoracic operations were being performed.

The next hospital we visited was about an hour’s bus ride from the city; a small facility specialising in plastics and reconstruction. We’d never have found it if we weren’t being taken there directly. Surrounded by utter devastation, this two-storey, beautifully presented building with a single radiology room (CR X-ray) and single radiographer, along with a small orthopaedic, plastics and surgical team, were performing near-miracles during normal circumstances, and were genuinely incredible in the crisis situation. Literally saving life and limb, with fantastic rehab facilities, I was genuinely impressed. The only thing they admitted to lacking was a radiologist, but this could be solved remotely fairly easily.

The entire radiology department!

The entire radiology department!

The only other hospital I chose to visit was Tribhuvan University Teaching Hospital, where I spent the morning sitting around discussing radiation safety standards with some of the more senior radiographers, and a couple of hours in the afternoon observing a complete lack of any in the actual department.

The layout of the general X-ray rooms was a single corridor with four rooms coming off it. The exposure consoles were in the corridor (!) and patients entered from a door on the opposite side of the room and exited via the console corridor (!) where they waited to collect their printed films and reports.

There was a wooden (not lead) screen in the corner of the room where patients would change into a gown (multiple use, not a clean one per person) while the previous patient was being examined. I assumed it must have been made of lead, but upon closer inspection it wasn’t. One thing that has always struck me about Nepal is that for a country with a very modest culture, there is absolutely zero expectation of privacy. At one point a 40 year old woman was dressing behind the screen when the radiographer brought in a teenage boy to change into the gown she had literally just taken off.

Relatives are expected to do everything for the patient, it’s common in countries like Nepal for nursing duties to be performed by a relative so when you are admitted there will be a couch or narrow gurney for your mother or daughter to sleep on. This extends to moving and handling- the Radiographers do nothing. Pat-slides in CT are done by the family while the clinical staff watch. An elderly lady, probably about 80kg was brought into the X-ray room by her granddaughter who was maybe 15 years old and all of 50kg, and she was expected to haul grandma out of the chair and onto the X-ray table. I couldn’t bear it so I helped move her, and was actually told not to, lest they come to expect it. Shocking. I pretended not to understand and continued anyway, but it was really awkward.

In fact to be honest the radiographers didn’t do a whole lot. They call the patient in, shout at them to get into the correct position, move the tube, open the collimators and go press the button (I won’t even go into the exposure factors they were using except to say 70kV/30mA for a chest??) then the CR cassette is put into a cubbyhole with the form and someone else collects it for processing. How are you going to improve your image quality and do things like reduce dose with collimation if you never see your image? I mean, shit it was fast! Patient in, press button, patient out. No repeats, no adapting technique; I was desperate to ask a radiologist how the hell they report these films with any confidence, but I chickened out.

The only saving grace is that the equipment was half decent so at least its modernity would (hopefully) have a dose reduction effect. They had a fancy new DSA suite, which was installed shortly before the earthquake and when they checked on it afterwards the C-arm had lurched across the room and smashed into a cabinet and the carbon fibre table had split down the middle from where it then smashed into the C-arm. Apparently the actual innards of the machine were fine though, and the controls were fully working so that’s good I guess.

Their new CT scanner (a Siemens 256 slice) was working hard since their old 16 slice broke down, and they had big plans to get a 3T MRI and DEXA suite which is great, but how about some proper changing cubicles first? And perhaps a lead coat or two for the relatives that accompany the patients?

It was especially frustrating because earlier in the day I had spoken with some of the more senior staff about implementing protocols and DRLs, and using IR(ME)R and IRR99 as the basis to write their own safety guidelines. Maybe it’ll trickle down if it happens. Maybe.

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Namaste

I’m sure I don’t need to tell you about the devastating earthquakes which hit Nepal in April and May this year. And if you’ve read this blog before, you may be aware that I spent a month in Pokhara (Nepal’s 2nd city) working in the radiology department of the biggest hospital there in 2011.

So it may not surprise you to read that I’ve just got home from Kathmandu after going out as part of a disaster response team made up of radiographers, radiologists and a sonographer. The team was assembled by RAD-AID, an American organisation which sends teams out to developing or crisis-hit countries which require radiological assistance.

Other members of the team had arrived before me, and were there when the 2nd earthquake struck. They were unharmed although understandably shaken (yes, pun intended) but the radiology team at Tribhuvan University Teaching Hospital took care of them well.

I was packing my bag and booking a cab to the airport when I heard about the second quake. I continued anyway as I figured that help would be even more pertinent now.

My connecting flight from Doha to Kathmandu was cancelled but I was bumped to another 7 hours later so that was fine. While on the plane I got chatting to my neighbour who was a Nepalese ex-pat living in Philadelphia and working as a structural engineer. She had got on the first flight she could, leaving behind a young child and a worried husband. She said that she felt she had no choice but to return home to help, and she was incredibly grateful to all the foreigners coming along to assist in the recovery. Less than 24 hours later I had already come to the conclusion that her skills were much more needed than mine, but I’ll get to that later.

I arrived at the airport to scenes of chaos, but nothing too different from my last arrival there. Our flight had been in a holding pattern for over an hour due to tail wind, and this had obviously affected other flights too, but the chaos was typical Kathmandu.

The hotel was gorgeous and I felt awful. On the drive through the city I saw only a glimpse of the devastation, and the sprawl of tents in every open space. To be staying in relative luxury (a roof, a bed, running water) felt wrong. I was also pretty impressed it was still intact.

I serendipitously bumped into the rest of my team on the stairs a few hours after arriving, so introductions were made and stories shared. S, the Sonographer, was my room-mate and we got on well fairly quickly. Z, the CT tech, was the team lead, and it was apparent fairly soon that he was a bit out of his depth, and F, the Radiologist was pretty chilled out about the whole affair.

It turned out that they had spent the past couple of days in the company of a local radiographer, visiting radiology departments throughout the city. This rang alarm bells immediately. I was lead to believe that there was a desperate need for outside help, and that’s why we were there. Apparently this was the case in the immediate aftermath of the first quake, as the department suffered an increased workload as well as staff fatalities and departures. There was also a radiographer at a hospital in Jiri (one of the worst hit areas, about 6 hours east of KTM) who had contacted the team after the first quake but had fallen ominously silent after the second.

So on my first day we continued the team’s main activity of visiting hospitals, uninvited. I’ll cover the individual days and visits in separate blog posts as they were informative, if next to useless.

Before I had arrived, the team were staying in another hotel and had met some really interesting characters. There was Peter and his documentary crew, Eric and Wes, who were filming and photographing Peter’s activities to be screened at an upcoming fundraiser. Peter’s story is long and impressive. He’s married to an American who is fluent in Nepali and has summited Everest several times. They’ve also adopted 3 Sherpa girls, raising and educating them in a much more luxurious lifestyle than the one they were born into. He runs a foundation committed to educating Nepali girls and lifting them out of poverty. More on Peter and his endeavours later.

Another amazing person is the one who Peter’s foundation is named after, Tsering, who owns the two hotels the team stayed in. A beautiful, ageless Tibetan woman with the ability to just appear whenever we needed her, and at times when we didn’t realise we needed her. Like the evening S and I went for a walk in a storm (out of choice) but after a while our legs were tired and we were soaking wet, facing a steep walk uphill when Tsering appeared out of nowhere and gave us a lift back to the hotel.

Someone who I only met a couple of days ago, but had become a legend, was Jason, a kiwi helicopter pilot who does regular 2 month stints in Nepal rescuing people from Everest. He just happened to be there during the quake and his skills were immediately put to use, rescuing nearly 200 people in the first few days after avalanches destroyed Base Camp. When I finally met him he casually mentioned he was receiving a medal from the President for his services last year. Who knows what he’ll get for this year’s effort. He also had a documentary team from New Zealand following him round, which he was very blasé about.

It was people like these who rescued my rescue mission.

I got frustrated pretty early on with the fruitless hospital tours, seeing fancy DR equipment, plenty of staff, and not many patients; as well as slightly put out (yet very hospitable) department managers, wondering quite what we were up to.

After all, what were we up to? A team of clinicians with skills but no equipment. Not even a portable ultrasound machine. I’d naïvely assumed that we’d have a portable DR X-ray machine and a couple of ultrasounds, but I was terribly wrong. That part of it was my fault, I had never been told that we would have some fancy bit of kit like the Xograph DRagon or whatever, but that was the problem- it was the things that I hadn’t been told.

Like, the fact that Z, our team leader had planned this trip (his first time leaving the USA) since last year, as a holiday / fact finding exercise for setting up long term fellowships at the teaching hospital and didn’t want to lose the money he’d spent on flights, so it was conveniently turned from an elective work placement into a disaster recovery mission when the earthquake struck. Yeah.

And the fact that our group hadn’t even been registered with the Ministry of Health (as is required, and only bloody polite, in these situations). This meant that not only were we unauthorised, but we were also excluded from info and meetings with other aid organisations which could have actually led to us providing help (although the bureaucracy of said meetings would have prevented us anyway). We gatecrashed those meetings when we found out the details, cos, y’know.

So I played along for a few days, and then S and I found other endeavours which were actually in need of outside assistance. The main one being an orphanage on the edge of the city which had become swamped with children from a city centre building which had been destroyed. This is where I met another inspirational person whose drive and determination was utterly incredible. Kalpana is a young woman who fell out of a tree as an infant (her earliest memories are of being in hospital, she doesn’t know how old she was) and broke her arm, so her parents abandoned her at the hospital. They abandoned her because she was literally “damaged goods” and would be of no use to them. She has had multiple surgeries to fix her arm, and yes, it has developed abnormally, but damn. Bearing in mind the things that she has achieved with one fully functioning arm, I’m intimidated to imagine what she’d have got up to with two!

Kalpana was resident at Balmandir Orphanage, and when she “aged out” she came back to work with the special needs children (she calls them her Tigers) as well as running an organisation called Creative Nepal, which aims to educate Nepali teenagers beyond basic level (one of them is a pharmacy student!) and empower them with skills that they can use to help others. Part of her education included a residential English course in London, and while she was there, she visited the coast for the first time, and went to the beach where I used to go when I bunked off school. Weird huh?

Kids in so called “developed countries” have it all on a plate and whine about hard work, when people like Kalpana and her housemates strive to improve their lives and those of others when they’d have every excuse to give up. I know, because I was one of those kids. I used to bunk off from my grammar school classes just because of bullying. It was easier to go sit on the beach.

So I spent most of my time at the orphanage because I felt like I could actually assist with looking after the children, rather than traipsing round local hospitals, getting interrogated by the staff.

Z guilt tripped me shortly after S left (her early departure was scheduled due to work commitments rather than frustration at the situation) and said “surely while you’re here you ought to do something vaguely radiological to justify the trip”. So I spent a morning shadowing radiographers at TUTH and wishing I was at the orphanage. Then at about 3pm I got a phone call from Kalpana saying that Upasana, a 9 year old with advanced Cerebral Palsy, had been admitted to hospital in respiratory distress. I took this as my cue to leave, and went with Kalpana to the hospital.

There was nothing I could have done as a radiographer at TUTH (their working practices are shocking, and their staffing is back to normal) but I was able to help with Upasana, if only for a short while.

While all this had been going on, tweets and Facebook messages were going up, detailing our rescue efforts. Incredibly misleading tweets and Facebook messages like the ones below:

 

Not a technologist, not doing anything radiological…

 

All that happened in this meeting was us displaying our ineptitude to a legitimate humanitarian aid group with amazing funding and infrastructure

 

This really annoyed me- this wasn’t anything to do with RAD-AID, this was Peter’s supply trip, S&I asked if we could tag along so we bought a load of sanitary supplies, hired a Jeep and joined the convoy to the village to hand them out. F was wearing scrubs. He shouldn’t have worn scrubs, because the villagers thought he was there to provide medical help and he couldn’t.

 

These “updates” really pissed me off, as it was yet more misinformation, attempting to legitimise our team’s presence in a disaster zone. About a week into the trip I was considering aborting early as I felt I was just wasting money by being there, and could potentially be a waste of resources if another quake hit and I needed help. Mid way through emailing the travel agent and feeling sorry for myself I got a message from Kalpana, nothing pertinent, just a “how’re you doing?” message. And I snapped out of it. From a selfish point of view I was really enjoying my time at the orphanage; the kids seemed to enjoy playing with me and I was able to be an extra pair of hands to feed the Tigers. So I stayed.

I barely saw the other RAD-AID guys, I occasionally bumped into them at breakfast, and one time I was returning from the orphanage just as they were leaving for dinner so I tagged along, but I wasn’t part of the team anymore.

And herein lies the problem- when I initially volunteered to go, I expected to pay for everything, naturally. Then I got an email saying that the Society of Radiographers (my Union and professional body) had agreed to fund it as part of their partnership with RAD-AID’s fellowship program. This was entirely without my input so I was quite pleasantly surprised, and somewhat relieved as I’ve moved house recently and my rent has significantly increased. And so my quandary: the intention of the trip justified SCOR funding (bear in mind the money they used comes from radiographers’ subscription fees) but the outcome certainly doesn’t. So what am I to do? I’ve paid for the hotel (which wasn’t a small amount) but do I offer to cover the flights as well? Bearing in mind I was mislead into travelling to Nepal to begin with.

But it was a life changing time, I fell head over heels in love, and have agreed to a life-long life-improving input into the lives of two very young girls (massive blog post to follow), and I met people who have completely changed my perspective on many things that I thought I had squared in my mind.

So there you are. Opinions are most welcome as I’m not entirely sure what mine is.

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Who Should Pay?

So the NHS is in crisis, A&E is fit to burst, there are no beds for those who need them. Plenty of opinion-givers have waded in on how to fix the problem, some qualified, some obviously not, and one of the solutions I keep seeing (from both sides) is, honestly quite disturbing.

Patients who turn up to A&E suffering injury or illness due to alcohol or drugs should pay for their treatment.

I know a few people who agree with this and genuinely believe it to be an acceptable way to deal with NHS overcrowding, and I’ve also seen comments to this effect beneath nearly every article about A&E online. I’ve even had people say to me “as someone who doesn’t drink, doesn’t it really piss you off having to deal with drunks at work?” which is something I find quite astonishing, because you wouldn’t say “as someone who doesn’t drive a car, doesn’t it really piss you off having to deal with injured car drivers?”.

Yes, it’s unpleasant being verbally and physically assaulted by intoxicated patients, but I’ve been punched and spat at by sober patients, and I’ve had drunk patients treat me with respect and decency whilst being incredibly apologetic for their state.

Plus “drunk patients” is an incredibly broad term, some recent examples that I can remember:
The woman who was beaten by her partner, who then spent the entire night drinking vodka to numb the pain as he wouldn’t let her leave the house until he had gone to work;
The hen party who’s taxi collided with a lorry, killing one of the occupants and seriously injuring the others;
The young child who had been bullied and beaten at school, so he snuck into his parent’s drinks cabinet and drank a bottle of liqueur, becoming violently ill;
The teenager who had been out celebrating his birthday and was assaulted by a group of men at the taxi rank putting him into a coma.

So which one would you send an invoice to? Fair enough we get plenty of people who get drunk, fall over and injure themselves as well, that’s pretty standard, but where do you draw the line? Some people say “if it’s self inflicted, they should pay” but again, what counts as self inflicted? The 70 year old lady who falls over her own slippers and breaks her hip- that’s entirely self inflicted, no one else could be blamed for that, but would you charge her for her treatment? How about mentally ill patients who attempt suicide because our woeful mental health services have failed them? Sports injuries- that 17 year old didn’t have to play rugby, he could have stayed indoors playing Xbox, but now he’s broken his leg, should he be paying? Motorbikes are dangerous, should all injured bikers receive a bill at the door?

Ultimately, no one wants to be injured, and it’s horrible when patients repeatedly apologise for taking up our time (that happens a lot on Christmas and New Year shifts), but the entire ethos of the NHS is to provide healthcare to the public, free of charge at the point of use. There is abuse of this system, yes, but it is minute in comparison to the amount of patients in genuine need of help. All this talk of putting patients off coming to A&E hurts even more when a patient (usually elderly, usually with a chronic injury or illness) tells me that they’ve been in pain for a while but “didn’t want to be a bother”.

The recent idea of sending an invoice showing “this is how much your treatment was worth” but without actually asking for payment would only put such patients off even more, and will undoubtably lead to the most vulnerable members of society dying long and unpleasant deaths so as “not to cause a fuss”.

I wonder whether the attitude towards users of the NHS has recently worsened due to the government’s swing towards privatisation; perhaps encouraging these opinions in the media and online will lead to more of an acceptance of the American way of “providing” healthcare, so that when it begins sneaking in subtley, people will welcome it, rather than abhor it.

“Well obviously I shouldn’t have to pay to have my appendix removed, but that alcoholic in bed 6 should be handed a bill on his way out.”

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Accident, Emergency, & Pandemonium

I’m sure you’ve all read the headlines, some of you may have seen the chaos for yourselves, either as a patient suffering from the chaos, or a staff member trying to work amongst it. A&E departments across the country are at breaking point. Or so the media would have you believe. In reality, the problem does not lie solely within A&E, and this is rarely the case when reports such as these hit the news.

Pretty much the only time an A&E department can solely be the point of failure is when a lot of people attend with acute injuries which do not require admission or long term treatment, such as sprains, cuts, etc. The problem that we are actually having is that the whole hospital is unable to cope, not just A&E.

In an ideal situation, where the NHS is properly funded, staffed, and resourced, here’s what would happen:

George has a stroke. His partner notices the signs immediately (due to the well advertised FAST public awareness campaign) and calls 999, and a well stocked ambulance with two paramedics (who have just enjoyed a 1 hour lunchbreak outside of their vehicle) arrives within 15 minutes and they quickly assess George and bring him to the nearest stroke unit. The thrombolysis team are waiting for him, he’s given a head CT scan on arrival, they see it’s ischaemic, and they decide to thrombolyse immediately having discussed the risks with George and his family. He’s moved out of resus and onto the stroke ward where the specialists can administer the clot-busting drugs and monitor him properly. Two days later he’s fully mobile and back to his old self, and goes home with his partner, and has regular visits from the community care team.

In the current situation where NHS funding is catastrophically low, George may have died at home, waiting for an ambulance. Or in resus, waiting for a CT scan, because one scanner was broken and the other one has a huge backlog. Or he may live, but the delay between the clot reaching his brain, and him being assessed by the stroke team is too long, and his condition worsens. There are no beds on the stroke ward so he stays in resus for 8 hours waiting to be moved. Eventually one of the stroke team calls in a favour from her friend on ITU who has just had a bed become free. She would prefer not to, as they’re not equipped for neuro patients, and the on-call reg will have to dash from one end of the hospital to the other to see George if his condition changes during the night, rather than being able to monitor him from the neuro unit. The next day a neuro bed has opened up, but three more stroke patients have arrived since George was admitted so there is some competition to get in. George’s partner has so many questions about his recovery, but there’s never a specialist available when she visits, so she has no idea how much longer he’ll be on ITU. A journalist submits an FOI to the trust about hospital admissions, and refers to George as a “bed blocker” in his front page article on how rubbish the hospital is.

“Bed blocker” is a ghastly term which seems to be adored by journalists. It makes you think of some useless lump of a person who refuses to leave the hospital and solely exists to inconvenience others. In reality that could be you, your mum, your dad, your gran… they’re human beings in need of care, but being inappropriately managed by the system. They’re rarely perfectly healthy people who enjoy being in hospital and don’t want to leave. Even in the case of people who are healthy enough to be discharged, it’s a lack of community care which is keeping them on the ward; ethically we can’t just send people out into the wilderness without follow-up care.

Another group which everyone seems to love blaming are so-called timewasters who come to A&E with the sniffles, or a minor rash. While this is a genuine issue which the NHS has to deal with, it’s not the cause of the current chaos. Minor ailments can be dealt with very easily, assuming that the healthcare staff aren’t completely overstretched dealing with not so minor complaints. A patient who comes in to A&E and then goes home rather than being admitted is really easy to see, assuming the resources are available. We investigate their illness/injury, treat it or provide advice, and then send them home, something which is (on paper) completely achievable within the 4 hour target. If they genuinely do not need medical intervention, or can be referred to their GP or a pharmacist, this can be dealt with by triage, and if the waiting room is heaving, they’re unlikely to want to wait hours and hours to get a paracetamol and a plaster.

So what’s causing the problem? Well, quite simplified, it’s an increase in acutely unwell patients and a decrease in facilities to treat them. The money isn’t there to provide the staff, and beds are being closed across the country. Due to fantastic medical and social advances, the population is getting older, and therefore becoming more vulnerable to illness, but unfortunately health and social care funding is barely meeting the rate of inflation.

The government are “dealing” with the situation by selling off any services that can generate profit, and chastising health workers for not being able to keep their heads above water.

We’re constantly getting patronising emails from the health secretary “reminding” us of the 4 hour target and all the other arbitrary benchmarks which do nothing but create further problems.

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24 Hours: Episode 1

So on Thursday night at 9pm the first episode of 24 Hours in A&E (that was filmed at my hospital) was aired. It was something of a big deal for us; there was a big viewing party at work, and my colleagues were talking about it all over social media. I was out at the time of airing, but rushed home to see what made the cut. I was both impressed and disappointed with the final program, so here’s my review.

First things first; there’s a radiographer in the intro! In previous series us radfolk didn’t seem to be properly represented, in fact, the only time you ever saw a radiographer would be in CT because that’s a fancy bit of expensive kit. But now we have one of our own, briefly, in the intro to the program! Awesome.

Things got annoying immediately after that, however. As I said in a previous post, Kerry, the patient with the amputated leg, arrived minutes before I started work; as I walked along the high street at about 19:40 I saw the helicopter fly over and land. In the program, they claim to get the 25 minute warning phonecall at 15:56 meaning she’d have landed by 16:30. Why? Why change this from the truth? Even the patient’s mum says that it was tea time when she went out on her bike- who has tea at 3 in the afternoon? You can also see in the footage- it’s the end of June and the sun is beginning to set! So straight away that’s really bugged me as it seems completely unnecessary, and kind of destroys the integrity of the journalism (it is meant to be a documentary, after all). I appreciate that sometimes they juggle the footage slightly (you’ll occasionally see gloves on/off out of order, or other things that have been moved about slightly but that’s art I guess) but why mess about with it this much? Grrrrr. It also really annoys me when they show the x-ray being done, and then afterwards they cut to footage of the scoop being removed (it’s a big metal stretcher that they carry the patient on, would kinda show up on imaging) because that has no creative merit either.

Maybe it was to add some “perspective” to the patient who kept whining about losing her leg because she had a small needle embedded in her foot (she arrived at about midday). I dunno.

Aside from all that, it was incredible (and incredibly weird) seeing colleagues on telly. But it was awesome seeing the patients’ stories, as we never get to follow up on what happens after they leave the hospital, in fact we rarely find out what happens after they leave the x-ray room!

There was also a radiographer count of five, which is impressive! And only one of those was in CT!

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Two Weeks ’til 24 Hours!

The date and details of the first episode has been released by Channel 4!

This is hugely exciting for my colleagues and I as we finally get to see ourselves on telly, and we can stop guessing which patients made the final cut.

The first episode features a patient I remember very clearly. She arrived by helicopter just as I walked onto the hospital site; the helicopter flew over me as I was making my way along the high street, and I thought to myself: “Uh oh, this could be trouble”. Our helipad closes at 20:00 and it was about 19:40 so they were cutting it very fine, and as it turns out the patient had come all the way from Essex so they’d been in the air a while.

When I got into the department I discovered that my colleague (who I’ll call Sam) was already in Resus for the hand-over (or leg-over in this case) so I stayed in x-ray and started working through the list of patients in our waiting room. When Sam returned, I was told about how the patient, Kerry, was a young woman involved in a motorbike crash which amputated her leg at the scene. And that one of the heli-med doctors handed the aforementioned leg (in a splint, covered in frozen peas and hash browns) to Sam for safekeeping while in Resus.

I really hope her facial expression was caught on camera.

A short while later the inevitable visit from orthopaedics happened, and upon returning from doing a mobile x-ray on Paediatric ITU I was told that Kerry was being taken to theatre, and that they may or may not need x-ray during the case.

I left theatre shortly before 2am, having spent a couple of hours with one of my favourite orthopods while he battled to not only fix the fracture above the amputation site, but to tidy things up as much as possible to give Kerry the best possible chance for a comfortable prosthesis.

I don’t remember a huge amount of the rest of the shift, maybe it’ll come back to me as I watch it on telly. The new series airs every Thursday at 21:00 starting on the 30th of October.

Read more about the new series here: http://www.channel4.com/info/press/programme-information/24-hours-in-a-e-series-7

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Blog a Day – A&E (9am-5pm Weekday)

So the first “typical day blog” is from A&E. Our department here has two x-ray rooms and ceiling mounted x-ray equipment in Resus (which you’ll see on Channel 4 this Autumn, no doubt!). On a normal weekday we have (ideally) two radiographers and a receptionist, and we work from 8:45 until 17:15. The areas we cover are Resus, Majors, and the Urgent Care Centre.

The day starts relatively slowly; a few walking patients from urgent care with minor injuries to their arms and legs, a couple of chest x-rays from Majors. Things remain calm until 10:15 when the trauma bleep goes off “Adult trauma team to A&E Resus…” I go to Resus to find out the details. On paper it’s a 40ish year old cyclist who’s been knocked off his bike by a bus. Open tibia fracture, but other than that all other obs are fine (he’s breathing, his blood pressure’s ok, and he’s fully responsive and coherent). He arrives fairly quickly; sometimes we get loads of notice before a trauma physically arrives, at other time the bleep is sent out when the patient is already here. When he’s wheeled in, he’s assigned a Resus bay and the paramedics give us a handover. He’s had morphine and his leg’s in a vacuum splint but the injury is easy to spot. Once on the Resus trolley the team begin the primary survey and everyone rushes round doing their jobs. It turns out that the patient was cycling along a blue cycle lane when a bus decided to squeeze between him and a car turning right. The cyclist slammed his brakes on and probably saved his own life, but the car behind the bus hit him and sent him flying over the bonnet. I’m asked to do chest and pelvis x-rays straight away to make sure he has no other serious injuries which are being masked by the pain in his leg. His pelvis is ok, but there’s a small pneumothorax at the top of his right lung. He’s taken to CT to check the blood flow to his leg, as well as the nature of the open fracture.

Back round in X-ray a queue has formed. Two chest pain patients are outside on trolleys, and there are three patients in the waiting area who haven’t been seen yet. Before I’ve had a chance to pick up the form for the next patient I hear the red phone ringing over in Resus. We get through the queue of patients just as the bleep goes off in response. “Adult trauma team to A&E Resus…” My colleague (who I’ll call Mark) goes round this time; similar story to the previous one, cyclist vs large vehicle, only this one’s much worse. The van that hit him went right over him, so he’s taken straight to CT after the handover and has extensive internal injuries including a spinal fracture (C4/5) and multiple pelvic fractures.

Meanwhile in X-ray a very unhappy paediatric patient has arrived with a very bent forearm. You can always tell it’s sunny outside when the trampolining injuries start arriving. She’s in agony, but is very cooperative (the seriously hurt ones usually are) and we get some perfect x-rays showing the greenstick fractures of her radius and ulna.

Then we get four stroke patients in a row (we “routinely” do chest X-rays for stroke patients in case of underlying chest pathology, or in case they aspirated fluid during the stroke, the usefulness of the X-rays is debatable, however).

The 5 year old with the broken arm comes back, this time in plaster, and lot less upset. She proudly tells me that she knows exactly what to do this time, and she definitely won’t cry. True to her word, we get perfect x-rays without me even touching her arm, and dad takes a photo of her giving the thumbs-up next to the x-ray machine.

The next child to come in is a bit different- “Paediatric trauma team to A&E Resus…” a two year old who was found, unresponsive and not breathing in his cot. Mum was absolutely inconsolable, screaming and crying (understandable, really) while the team attempted to resuscitate her child. He had a pulse, but his breathing was infrequent and shallow, so I did a chest x-ray, after he was intubated and it looked like he’d inhaled fluid (possibly vomit).

Things went quiet over lunchtime, with only a few chest x-rays coming in from Majors, and a psychiatric patient who had told her carer that she’d swallowed razorblades. It turns out from the abdomen x-ray that she’d actually swallowed parts from a pen, which was a relief.

As I escorted her back to her cubicle in Majors, a mortuary box was wheeled past me towards Resus for the second cyclist. Another unsurprising and unnecessary death on London’s roads.

Just as Mark made a comment about how calm things had been for the past couple of hours, the helipad response team sprinted past; the helipad had only recently opened and we were still in early double figures for patients visiting us via the roof so it was still very much a novelty. I dashed outside to see if I could watch it land, but it had already touched down by the time I got to a vantage point.

This was a straight-to-CT trauma patient who had fallen from a height of about 20 feet onto concrete. After his CT scan and on his way up to ITU we did some x-rays of his arms as it turned out that on top of the extensive lower leg injuries he’d sustained, he’d also broken his thumb…

We had a few more weather-related injuries (mostly sports, but two more trampolines), and a motorbike rider who broke his wrist in an altercation with a pothole. And then to finish the shift off, a woman came in who had sat on a wine glass and had shards embedded in her buttock- an accident which happens more often than you’d think, often enough for me to have perfected the tangential buttock projection

At 17:15 the long day people (who work until 20:00) arrive to take over for the evening. Looking at the worklist at the end of the day, I’d say we’d had at least 60 patients during the shift, fairly unremarkable for our usual workload.

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Blog a Day

A while ago I was asked by a prospective radiography student what an average day is like for a radiographer. I answered that there was no such thing as an average day as we cover so many different modalities and areas, but within those areas it’s entirely possible to have an average day, so here goes!

I wrote these blogs over the summer but have waited to publish them to avoid any chance of patients recognising themselves (in the extremely unlikely event of them reading this). Also, as I was writing the notes throughout the day, the posts themselves required quite a lot of editing and proof reading! Please bear in mind that these posts relate to a typical day in my hospital only, others may be quieter / busier or have a completely different structure.

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Industrial Inaction

It’s been ages since I last blogged, and there’s a reason for that. In the past, something would come to mind while I was at work, and I’d jot down a few points or occasionally even a full post if there wasn’t much going on. However, the days of “not much going on” seem to have passed. Since the opening of the helipad, and the major trauma network policy being that all trauma patients come to us rather than to a DGH, the workload at the hospital has drastically increased.

Other than that, there have been a few other developments; 24 Hours in A&E have been and gone, the cameras have been taken down, the fixings painted over, and the program will be aired sometime before Christmas apparently. All very exciting. We don’t yet know which particular time periods have been covered on the program, but the final weekend of filming was incredibly dramatic so I’d be very surprised if at least some of it doesn’t make the cut.

We’ve also had a load of brand new Band 5 radiographers start in the department so that’s been interesting, it’s a busy London department, so plenty of people come and go, but it’s been a while since so many newbies showed up in one go. One thing that’s quite remarkable about this graduating year group (if our newbies are a representative sample) is how many of them went on elective placements abroad; Sweden, Argentina, Singapore… all over the place. It’s very encouraging to see, because (while I appreciate not everyone is able to) it gives them the opportunity to experience healthcare provision from a very different perspective. Some countries are very similar to the UK in the way they provide radiology services, others are completely different. Radiation protection is a subject which varies greatly, and as I saw in Nepal, in some places the concept does not exist, and from chatting to some of our new staff they also saw that elsewhere in the world. Also, while the UK tends to be very modern generally, because our healthcare is provided through taxation, funding is limited, so we don’t always have the more cutting edge equipment available to us. In countries like Singapore, you get to play with the really fun toys.

And on the subject of funding…

The current pressing matter is that of industrial action; several unions have balloted their members, including the Society of Radiographers, and a vote to strike has been made. It wasn’t an easy decision, withdrawing labour is usually a last resort, especially when it is going to have an effect on patients, but since the Tories have been in power, NHS staff have effectively endured continuous pay cuts, and it’s got to a point where something must be done. Personally, I feel hugely uncomfortable- I’ve attended many protests and handed out leaflets to the public, but I have never participated in strike action before, in fact until the two ballot papers arrived at my home last month, I’d never even seen such paperwork before. I was even more conflicted when the ballot result was returned- a turnout of 41% with only 53.3% voting for strike action, and 78.9% voting for action short of a strike. So in reality, a fifth of radiographers voted to strike. Luckily there is currently no minimum turnout to validate a strike, and in my opinion if there was to be one implemented, the same should apply to a general election.

But nevertheless, a strike has been called. so next Monday radiographers across the UK will walk out at 9am and not return to work until 1pm, and I shall be one of them. I’m quite disgusted with the way that the NHS has been treated by the government, with large chunks being sold off to politicians’ friends for a hefty profit, cuts to funding, and disparaging comments being made by those in a position of immense priviledge. Yesterday a significantly larger strike took place, with Unison members on the picket line from 7am. I joined the picket for an hour before work yesterday, and it was lovely to bump into June Hautot again, a local “trouble maker” as she has been described. I doubt we’ll have as much support on the 20th, but I’ll certainly be there regardless of the weather!

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