Archive for the ‘Nepal’ Category

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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Inter-Professional Spurning

On Friday I finished the practical aspect of a degree module called “Inter-Professional Learning” (IPL). For two weeks every academic year, healthcare students from Southampton and Portsmouth University are bundled together into groups of 10 and given a project to do. IPL “strives to improve communication and working relationships between professionals, and helps them deliver high quality services in increasingly challenging times.” The idea being that if doctors, nurses, podiatrists, radiographers etc work together before they qualify, it will hopefully enable them to work together even more smoothly throughout their careers.

Unfortunately my experience of IPL has taught me very little about other healthcare professions (except pharmacists, which I’ll come to later) and in most cases it has reinforced some stereotypes that I know aren’t true.

For example, all of the medical students I have worked with on IPL have been incredibly self important and made it very clear that they had much better things to do (as if the rest of the group desperately wanted to be there) and in a few cases they even went as far as not bothering to show up. The male med student in the first year showed up on day 1 and day 14, and spent the time in between playing rugby somewhere in Europe.

Until this year, all of the social work students in my group have been paranoid and defensive, an attitude which can’t have been helped by the introductory lecture we had at the beginning of the first IPL which basically reminded everyone that people always blame social workers when a child is hurt or killed. I’m sure this was meant to be helpful, but it put my group’s social work student into a really foul and indignant mood.

The nurse from IPL1 was an alt-med nutter who insisted that humans don’t need vaccines as homeopathy is a much more effective and safe method of protecting yourself. Terrifying.

So yes, I am cynical about the effectiveness of IPL in its mission to improve communication and attitudes within a multi-disciplinary team. Especially bearing in mind I had the best IPL-like experience anyone could wish for whilst living in the Pokhara house; working, resting and playing with healthcare professionals from all over the world. I learnt more about what nurses and doctors do in that month that I have done over the duration of my entire degree so far. I was hugely impressed by their knowledge, and I really enjoyed our dinner conversations about the day we’d just had.

Last year on IPL2 I did actually learn a fair bit about pharmacy, but it had nothing to do with IPL itself. It was in the car journeys to the placement site, where the pharmacist and I had many really interesting conversations about the legal side to the profession, as well as discussing the vast amount of mathematical prowess required.

I follow a few medics on Twitter; some are students, some are long-qualified, and some have only just registered with the GMC. They all regularly provide me with really interesting information about their profession and healthcare in general, and there’s even a Twitter journal club where papers are reviewed and critiqued by anyone with an interest.

I have never felt compelled to stay in touch with any IPL group member once the sessions have finished, but this weekend I’m driving over 500 miles for a reunion with my Pokhara housemates (those on this side of the Atlantic anyway).

I suppose what I’m saying is that healthcare workers and students need to be personally interested in engaging with each other, as no amount of forced role-playing or ice breaking sessions will achieve a truly cohesive working environment. It is a sad fact of life that some people are content to go through their lives with the bare minimum of effort and interest, and I guess that’s why IPL has to exist. But at least those people will never become public health bores like me.

:-/

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Hydronephrosis Boy

There are a few cases which I didn’t fully blog about when I was in Nepal, this is one of them. The photos aren’t particularly great quality as the light was low and I didn’t think that using flash photography during a surgical procedure was prudent!

An 18 month old boy with hydronephrosis was sent down to CT prior to surgery, to establish the entry point for a percutaneous nephrostomy tube. Hydronephrosis is the retention and collection of fluid within the kidney. In this particular case, the left kidney had become so distended and dilated that the overall size was in excess of 15cm in diameter. This giant mass was palpable and visible, and obviously causing discomfort as well as internal damage.

The boy was understandably distressed, and therefore required sedation before the CT scan. I will admit it was difficult not to raise a smile watching this tiny child space out in front of me:

Even though he had been sedated, he was pretty feisty and fought the drugs and the doctors as much as possible, but it wasn’t long before he realised that resistance was futile:

Following the scan, the boy’s father carried him across the corridor to the ultrasound room where more sedation was administered- no general anaesthetic was given.

The boy was still quite happy and smiley at this point; waving and grinning at Daniela and I as we watched from the foot of the bed.

Within seconds the sedation took effect and he crashed out.

Then the room filled with white coats and the procedure began. Unfortunately the cold iodine swab brought him out of his nap, so he had to be restrained. The gloves may be “sterile” but the sheets and equipment are not.

Using ultrasound guidance, the initial incision was made, without local anaesthetic, and a large hollow needle was inserted into the boy’s left renal area. The noises that tiny little person made seemed impossible. He kicked and screamed and cried, but like no crying I’d ever heard before, this was terrified, tortured wailing. More hands appeared, holding his wriggling little body down, until it became nearly impossible to follow what was actually occurring:

The needle had to be forced through muscle and tissue to get into the distended kidney, and after a bit of “adjustment” (read: wiggling) fluid trickled out of the end onto the bed. What looked like a pig-tail catheter was inserted and the needle was retracted. The catheter was larger than the needle and required more force to put in place, but this didn’t result in more screaming and writhing, in fact, the boy’s body went limp and silent as he passed out from the pain.

I looked over my shoulder to where his father had been stood, but he had left the room, seemingly unable to watch his son endure such a traumatising procedure.

The catheter was fully inserted and a tube and bag were attached, and urine began draining out.

The assortment of tubes were connected and then sutured into place with a shaky hand rather than a needle driver, and the whole area was dressed and covered in sticking plaster. Then, as quickly as the swarm arrived, it left.

The boy’s father was standing outside the door, unsure of whether he should go in. Daniela and I motioned that he could come in and see his son, so he gingerly entered the room, but kept his distance from the tiny unconscious body in front of him. We left him to be alone with his child.

I don’t doubt for a second that he was immensely grateful to the doctors, after all, without the nephrostomy his son would have certainly been at risk of kidney failure and probably death. However, one major difference between Nepali and British healthcare (I can’t comment on any other as I haven’t experienced it) is that in the UK you are given armfuls of paperwork and forms both before and after any medical procedure. Next time you’re in A&E have a look at the number of leaflets on display, for everything from Caring for a dislocated shoulder to Walking with crutches.

Informed consent is an integral part of healthcare in the NHS. The doctors will explain everything in great detail before you’re even in a hospital gown, because you can’t fully consent to something if you don’t know what it entails. This means that you know exactly what’s going to happen, and in theory reduces the likelihood of legal action should things go awry.

At Manipal Hospital, walking through the doors is an expression of full consent. In turning up at the hospital you are declaring that you want to be treated by any means, with the only barrier being cost. It would be impractical to explain the procedure to every patient; they don’t care what size IV cannula you’re using, they just want the pain to stop so they can go back to work and provide for their families. I imagine it would also probably scare them if they knew every detail of what they were about to face.

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I don’t miss…

This post is an attempt to smack myself back into a normal state of mind, as this whole depressive nonsense is ridiculous after 3 weeks.

…Untangling myself from the mosquito net every morning.

…Attempting to seal myself inside the mosquito net every night, only to find one of the winged bastards was already inside waiting for me.

…Which brings me to another point: the bloody insects! Everywhere! Bitey ones, crawly ones, flying ones, noisy ones… Also, arachnids. Bleh.

…Sharing a bedroom- no offence Prathyusha, but I haven’t had to share a bedroom like that since I was about 10 so it took a bit of getting used to!

…Showers. With the exception of the amazing shower at the Sacred Valley Hotel, showering was very hit and miss. In the house there were two showerheads in each bathroom, one was freezing and the other was scalding, so to have a reasonable temperature you had to ignore the Ghostbusters advice and cross the streams.

…The HONKING, the incessant HONKING. Drivers in Nepal must be under the impression that if their car horn goes unused for more than 8 seconds, the car will break down. Therefore any journey by road is accompanied by a very distinctive and annoying soundtrack. On the 5 hour trip back from Chitwan it got ridiculous; you couldn’t sleep, read or have a conversation.

…Also, the state of the roads made for uncomfortable journeys, the most painful being the trip to the Green Pastures Leprosy Hospital. The combination of knackered suspension and bumpy roads led to aching bones and bodies.

The heat/humidity. Well I’m not sure now actually, it’s so bloody freezing in the UK that I think I prefer being too hot as it wasn’t actually too unpleasant.

…Kathmandu. I really really did not enjoy KTM; it was busy, noisy, crowded, and full of annoying Americans and English people.

…The language barrier. Most people were hugely accommodating, and by that, I mean they went out of their way to make me feel welcome by speaking English to me, and letting me be involved. But there were a few occasions (and most of these were in the final week, outside the hospital) where things got quite unpleasant and awkward, where people were obviously talking about me in Nepalese and certain hand gestures insinuated that the conversation was less than polite.

…Busy Bee, after midnight. We had a fantastic time at Busy Bee, it was so much fun and many amazing nights were spent there, but for some reason, after midnight, the atmosphere would suddenly and dramatically change to a more uncomfortable one as the Nepalese men would almost compete for the attention of the Western women.

…The suffering. It was really difficult watching the anguish that people experienced daily. The children especially were so resilient, enduring procedures and investigations which made my eyes water. And the conditions that patients would present with would be chronic and usually life threatening. I have another post to write about the hydronephrostomy which I observed, which will highlight this more than adequately.

But it was still the most amazing month of my life and I would go back there in a heartbeat.

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I miss…

…Krishna’s amazing cooking; what he can rustle up without an oven is nothing short of witchcraft.

…The breathtaking views of the mountains.

…Long energetic chats over dinner, sharing stories about the events of the day.

…Lazy evenings in the jazz bar, listening to soothing music and watching the lights reflect off the lake.

…Dancing to the covers band in Busy Bees til the early hours, meeting friends and making new ones.

…Sitting by the lake at midnight, watching the fireflies dance and listening to the frog chorus.

…Getting lunch in the basement canteen and swapping stories of the day so far.

…The chaotic bus ride to the hospital: “MANIPALMANIPALMANIPAL!”

…Haggling for taxis outside Metro City Hospital: “We’re not bloody tourists, don’t try to extort us!”

…Padma’s infectious smile.

…Trying to fit 6 people into a taxi on the way back from Lakeside at 1am, and REFUSING to pay NR200 for the pleasure.

…The epic monsoon rain, thunderstorms and beautiful lightning creating dramatic silhouettes of the mountains.

…BBQs on the roof!

…Admiring the incredible bravery and strength of the patients, some of whom reduced me to tears on the bus home.

…Watching Anna lust after paintings in the store near Fishtail.

…Chatting to random strangers in the street about anything from music to medicine, and their gratitude when they discover I’m not just some trekker passing through.

…Practising my (frankly rather awful) Nepali with patients while they wait for their x-rays.

…Dancing on the roof to avoid the bugs while attempting to get a Broadlink signal.

…Having a mocktail in Monsoon Bar and watching the police train in the field behind.

…Running through the monsoon like a nutter while the locals laugh at me from the shelter of the shops.

…Perfecting my Dr Alan Statham impression by flouncing through the basement in my white coat.

…Admiring the elite haggling skills of my housemates.

…Playing Angry Birds with the rad dept.

…The daily cups of seriously tasty tea made by the nurses.

…Singing La Bamba and dancing with a multicoloured umbrella outside the ATM while supposedly “protecting” Jay. (Yes, this only happened once but I miss it every day)

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Home Sweet Home?

The second leg of the flight was interesting. I had a seat in the row directly behind first class so the leg room was vastly improved, and there was no one in the seat next to me… until the child belonging to the family across the aisle decided to sit there and continually bash into me and generally be really bloody annoying. No sleep for me then.

Then about halfway into the flight some crazy drunk lady decided to go on a loud racist rant-fest. She started shouting about how she wanted a Business Class upgrade and was declined even though there were empty seats “because Qatar Airways don’t want white people in Business Class!” which I found hilarious as when I walked through there earlier there were loads of white people enjoying their overpriced seats. So her tirade went on for about half an hour by which time everyone around me was muttering words to the effect of “shut up” as it had gotten rather tedious.

Then, when we eventually landed at Heathrow, none of us could leave for about 20 minutes while armed police boarded the plane to deal with the (now rather quite calm) situation.

When we were allowed off the plane, there was then the tense 15 minute wait at the luggage carousel, and then I met Matt at the arrivals gate.

After a long drive home (the A3 was closed so we ended up going round in circles trying to follow the diversion) we got back at about midnight.

So here’s the emo bit: after an awesome month, it’s actually been a bit depressing being back in Portsmouth. The mundanity of shopping in ASDA is tenfold now, and I just want to go back to Pokhara as soon as possible.

I miss Nepal.

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Go WEST!

Sat in Doha airport having found the wifi and the power outlets, but I made the mistake of putting my power cables in my checked baggage.
iPhone – 47%, laptop – 66%
I do however have my Kindle but I can’t read when it’s noisy (and boy is it noisy here) so I might go to the prayer room and worship at the altar of Carl Sagan if I’m allowed.

On a side note some crazy Italian-sounding lady is lurking next to me asking for technical support… seriously, it’s a free wifi hotspot, if you can’t figure out how to use it, it’s probably for the best.

So I got about 2 hours sleep last night, partly due to getting back to the hotel so late and partly due to the loudest monsoon rain so far. So I’m knackered. I left the hotel at 6am, at the same time as Daniel, an Icelandic guy who was staying at the one next door. He was going to the bus station to hop on the Greenline to Pokhara which is on the way to the airport so we shared a cab as it was pissing it down and there was only one in sight. I was a tad jealous, and told him so, and he was relieved to hear that Pokhara is nothing like Kathmandu. It took a fair bit of will power (and admittedly some common sense) to stay in the cab and go to the airport rather than following him to Pokhara.

The airport was chaotic, which I had anticipated, but not to the degree that I experienced this morning. I dashed out of the taxi, through the monsoon to the departures area, where there’s basically a load of different entrances depending on what airline you’re flying with, although they all open into the same check-in hall. All the doors were closed when I arrived, as was the airport. This remained the case for an hour, which was fun, and then they opened the door next to the one I was meant to go through, so I thought “bugger it” and went in anyway. It’s not exactly a finely tuned system at Kathmandu Airport, I wasn’t going to mess up their perfect check-in process.

Another slight issue was my lack of boarding pass having checked in online and being minus a printer, but apparently waving a British passport around does the trick, which was good. I will be very surprised if my baggage is waiting for me in Heathrow, however, as they didn’t stick the tag on properly and I watched it fall off the baggage carousel when it got to the airside of the conveyour belt. Ah well, nuttin I can do.

In the airport, I bumped into Corey, an American guy who we kept meeting at Busy Bees, and the last time I saw him he couldn’t afford his bar tab, so Kat kindly bailed him out by giving her phone as a deposit. I frantically texted her to ask if she ever got her money back, but by the time she replied he was already airborne. It’s weird that I keep meeting Pokhara people in Kathmandu, that’s the third time it’s happened.

Anyway, eventually the airport opened properly, flights resumed, and mine was only running an hour late so it wasn’t too bad. Except yet again some asshole had nicked my seat, but as I wasn’t running late this time, I decided to make an issue of it. Turns out he was meant to be in the seat next to mine, but had decided to take the window seat instead so the steward bumped him across. This meant I had to sit next to him for 5 hours, which was unpleasant as he was borderline obese, rather sweaty, and refused to turn his mobile phone off until the steward threatened to kick him off the plane.

I managed about an hour’s sleep I think, but the seats weren’t far enough apart to accomodate my femurs so I was hunched at a very awkward angle. Moan moan moan… bitch bitch bitch. Can you tell I’m tired?

Yeah, so Doha is not my kinda place. The airport stinks of money and so do the people in it. I’ve not dared to find out how much a cup of tea would be, but if it’s what I expect then I’ll improvise. I have some tea bags in my hand luggage, so all I need is a mug, some hot water, and some milk. Oh, and a spoon.

Wish me luck.

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Last Night in KTM

Today was my last full day and night in Nepal and it could have been better! But it could have been worse.

It rained all day, so I tried to get around and see a bit of Kathmandu, I even downloaded a walking tour onto my iPhone but I couldn’t really walk around with my phone in my hand as it would have drowned. So I walked down to Durbar Square to see the temples and places like Freak Street, but there were military folk everywhere and I really don’t like how they stand with their fingers on the trigger while they’re milling about so I had a quick nose around and then wandered elsewhere. It wasn’t very easy to get around though as the streets are so narrow and everyone’s got umbrellas, and occasionally a rickshaw or motorbike will squeeze through so making progress is difficult. I gave up and headed back to Thamel where at least the streets are slightly more negotiable (omg I miss Pokhara so much) and picked up a few souveniers for next to nothing, as the shops weren’t selling at all today. I bought a silk dress for NR800 when the guy originally wanted NR2800 so it just shows how much profit they normally make!

So I mooched around for a bit, somewhat annoyed that I couldn’t see the city, and ended up at a hairdressers for no apparent reason. Got a haircut for NR275 but gave the change from a 500 note as a tip to the hairdresser as she did such a good job (I think so anyway). So that’s a cut and blow dry for less than a fiver.

Then I went over to the Last Resort office to collect my DVD from yesterday’s jump. The guy at the shop was the same one who harnessed me up on the bridge; he had a wicked sense of humour up there and it was still in action back on the ground, so that was cool. Then I went over to a restaurant for dinner as I had somehow managed to miss lunch. During dinner, Chloe, one of the girls who was at the Last Resort yesterday came over and joined me, and the evening picked up from there. We finished dinner and headed upstairs to Tom and Jerry’s-
holy shit there was just the loudest bang and a flash, and then the power went… eek! Anyway…
ahem. So we went to the bar and chatted for a while about all sorts, although a major theme was Auroville, a very new age concept for a sustainable community. Look it up, it seems incredible but a tad cultish, if you know what I mean. Plus there’s some controversy about paedophilia which is never a good sign.

Anyway we chatted for a while and then a Nepali guy (whose name I can’t remember) came over, I chatted to him before leaving for the Last Resort, and he wished me luck and told me if he didn’t see me back in the bar on Thursday then it means I fell to my death in the Bhote Kosi. So he and his mates came over and sat with us and we talked about all sorts of things until a vague kind of argument broke out between the guy and Chloe about trekking knowledge. I stayed out of it but it was all fairly good humoured anyway.

We all chatted until after midnight when we all got kicked out, so I ran back to the hotel in the rain, where I’m now writing this post. I ought to get to bed as I have to be up in 4 hours for my flight…

Good night!

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