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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