Kings College London 2010

Medical, Nepal Pokhara

Matt found the relationship he developed with his supervisor allowed him to become actively involved with ward rounds and clinics. The skills he developed under their tuition gave him excellent grounding for his FY1 year and taught him a lot about examination, surgical technique and decision making when working with limited resources.
 
Having never been travelling before, I was a little apprehensive about visiting Nepal for my elective. My knowledge of the country was very limited before I arrived so I did not know what to expect. However, when the time came to leave and fly back, I did not want to go!

The Work the World house in Pokhara was a lovely place to live. It was a convenient walking distance from the hospital and Lakeside. The rooms were very comfortable and some had an ensuite bathroom. The views of the mountains from the balcony were incredible. We had our breakfast and evening meals cooked for us by the Work the World chef and they were delicious. It gave us the opportunity to sample the local foods and delicacies. We were given some Nepalese language lessons which helped us to introduce ourselves to the local people and help with day to day activities such as going shopping and ordering food. The housekeeper kept the house very clean and tidy and there was always a security guard on the gate so we always felt safe. The program manager was always available to answer questions and provide help and advice where it was needed. The electricity was turned off by the government for several hours during the day but there were always lamps provided to light the house. We were very well looked after.

The hospital was funded by the Nepalese Government. Patients pay for treatment in Nepal but this hospital aimed to provide services to patients at cheaper prices enabling those with limited finances (the majority of people in Nepal) to have the treatment that they needed. On arrival, I was struck by the warm reception received from the patients. They would smile at me and some would even touch my arm. They showed great respect to us and were very welcoming, giving the customary greeting of "Namaste" (I bow to the God within you) each time we saw them.  The staff were most welcoming and were intrigued to learn about practices in the UK.

The hospital has adopted the 'Safe Motherhood Programme' and since its initiation in 2004, it has aimed to improve health and survival of both mother and baby. Also, it has helped improve access to obstetric care in remote areas and improved access to clinical resources helping ensure safe deliveries. Previously, it was the policy that patients would pay for the treatment received. However, since the programme was adopted, all obstetric care is free and each new mother is given 1000 rupees upon leaving the hospital to help them get established in their role as a mother. The obstetrics department boasts no maternal mortality during the last 3 years despite approximately 8,000 women delivering under their care each year. According to the consultants, the number of mothers that deliver in the hospital represents 10% of all births which is in stark contrast to the number of home deliveries that take place in the UK.

Very soon into my elective, I was struck by the poverty of the country which is no less illustrated by the fact that the Nepalese Government sells electricity to India, resulting in the Nepalese people living without electricity up to 12 hours each day. The theme of poverty extended into the hospital. The maternity wards consisted of concrete walls with paint falling off, and white framed beds in wards filled to capacity. Infection control precautions were minimal and there was only one sharps bin observed on the ward that was overflowing. Syringes were often left at the bedside for re-use. No bedding or sheets were available for patients and they were expected to bring their own bedding. Occasionally, there was a cot at the end of the bed, otherwise babies slept with the mother.  However, the patients were very grateful for the treatment that they received and there were no obvious complaints.

I attended the ward rounds each day. In most cases, each patient had an abdominal and internal examination and it was not always obvious that consent was gained. Also, there was no concern with regards to privacy for the patient as there were no curtains around the beds. Latex gloves were used for internal examinations but these are recycled and washed at the end of the ward round for re-use.  This was the accepted way of practice. The consultants persistently apologised for their practice but stressed that the lack of resources left them with little choice.

Ultrasound has limited availability so clinicians rely on clinical examination alone which was very impressive. They do not have Doppler ultrasound probes so their skills of using a Pinard's stethoscope were admirable. Although ward rounds were conducted in Nepalese, the consultant would always translate what had been said. Patient notes are written in English which meant that interpreting results and reviewing management plans was straightforward. It allowed the opportunity to get involved in the round and I frequently wrote in the notes which was good practice for my FY1 year. I regularly performed abdominal examinations to assess fetal lie, presentation and engagement which increased my confidence with these skills. 

Antenatal clinics were very different to those in UK hospitals. The first contrast was with the number of patients. During a morning clinic, it was usual for them to see 200-300 patients. There was a security guard on the door directing them to one of two tables. They would provide their notes, the EDD and gestational age would be calculated, they would be examined on a couch behind a curtain and then sent for any outstanding blood tests.  They would return for the final review of the results and then sent home. It was an incredible experience to witness. There was very little communication and counselling between doctor and patient.  It mirrored a production line rather than a medical clinic. However, given the number of patients, they had no choice. Each patient was entitled to 4 antenatal clinic visits and women were turned away if they exceeded this. I assisted in clinic by helping to calculate the EDD and the gestational age, and was able to examine numerous pregnant abdomens of varying gestations which has improved my confidence in my examination skills. I was able to accurately use a Pinard's stethoscope.

The labour area was very different to UK labour wards. Women in labour were brought into the first stage labour room. There were 5 beds in this room but frequently there would be around 10 patients occupying all available space. Again, privacy was not considered a requirement and family members assisted the midwives in looking after the women's needs. No toilet was available; a plastic bowel was provided under the bed. When the woman was crowning, they were taken in a wheelchair or walked to the delivery room which had the capacity to have 3 women present at a time again without curtains for privacy. They would climb up on to a small raised couch and on one occasion, there were 10 students present for a delivery. Similar to the UK, one midwife would be in overall charge of the birth and give encouragement and reassurance. The father was not present throughout any part of the birth and female members of the family were not allowed into the delivery room. Another difference between obstetric practice in Nepal and the UK was that every woman who delivered in the hospital was given an episiotomy. It was considered standard practice of the delivery procedure.

With the baby delivered and the cord cut, the baby was taken to a resuscitare within the labour room. They were cleaned, weighed and checked for abnormalities before being wrapped in a blanket and shown to the mother before being taken outside and given to the awaiting family. Unlike the UK, an identity bracelet was not used, only a sticky label stuck onto the blanket so it was easy to see how mistakes could be made. A note of happiness was visible when a woman gave delivered a boy as male children were more desired due to perceived advantages to the family future.

Another difference between the Nepalese and the UK women was that the Nepalese women were much calmer during labour. They did not have access to the pain relief that occurs in the UK. They accepted that this was the way of life and dealt with it admirably.  On one occasion I was very privileged to assist with the delivery of a baby girl. After delivery, I delivered the placenta using controlled cord traction. The principles of the delivery process are similar to the UK, the difference being that they have different ways of applying it based on the limited resources available. However, they do not check the placenta to make sure that all the membranes and cotyledons are present and they do not check to see how many arteries are present in the cord, something always performed at UHNS.

A notable birth that I witnessed was a 20 year old girl in labour with a breech presentation baby delivering vaginally. I took part in an obstetric emergency training session at UHNS and was shown how to deliver a breech baby. The same principles were applied in this situation and I was impressed with how the midwife took control and delivered the baby with ease. Unfortunately, shortly after the birth of the baby boy, it became clear that all was not well. He was struggling to breathe and despite suction and repeated attempts to stimulate him he was only making feeble efforts. He also had extremely flexible joints which the midwife noticed was more than usually expected.  Very sadly, he died a few hours later.

I readily took the opportunity to spend time in theatre. Unlike the UK, the hospital has 'theatre days' where the operating theatres are used by one speciality. The equipment was very old and the operating table had a cloth on it that lay underneath all the patients on that particular list. Scrub nurses set up their trolleys in a similar fashion to the UK, and a kettle of boiling water was brought through to wash the swabs. Aseptic technique was maintained and all staff were conscious of reducing infection risk. Due to the culture of Nepal, people are reluctant to visit the doctor and therefore pathology is more advanced than that commonly seen in the UK. An example was a woman who presented with mild abdominal discomfort that had worsened. Examination revealed a mass in her abdomen and surgery was scheduled. A large ovarian cyst was identified that had undergone torsion and necrosis. It was approximately 15cm in diameter and was removed and sent to histology to assess whether it was benign or malignant.

I observed several caesarean sections. In the UK, the pfannenstiel incision is routinely used but some of obstetricians in Nepal use vertical incisions routinely. The operation itself is very similar to that performed in the UK. They are less concerned with regards to the cosmetic appearance of scars and do not use subcuticular suturing. Also, in the UK the uterus is left in the abdomen whilst the uterine incision is closed. However, in every case I saw, the uterus was taken out of the abdomen and wrapped in a swab placed in hot water to aid involution. It was very interesting to observe it contract to a fraction of its original pregnant capacity.

A very interesting operation concerned a woman of 23 years old who had travelled a great distance with suspected ectopic rupture. She was taken to theatre shortly after arrival and the surgeon discovered an abdomen full of blood. The blood was removed and to my shock, an 18 week-old foetus was also removed. It was an emotional moment for all present and I felt very guilty to be curious to see the development of the fetus but then to appreciate that this was such a tragic incident for the mother. The surgeon proceeded to remove the blood and located the site of the bleeding. The woman had a bicornuate uterus and the left horn had ruptured leading to death of the fetus and extensive bleeding into the abdomen. I had never seen a bicornuate uterus, or a ruptured ectopic so this was a very interesting operation to observe, aside from the obvious emotional distress. The surgeon proceeded to suture the area of rupture and cleaned the abdomen. I was impressed by the Dr's calm and collected approach to the surgery and the improvisation she used to deal with an unexpected finding. The lady made a good recovery.

During my first 4 weeks in Pokhara, I also visited a local orphanage. It was an amazing experience. The orphanage caters for 75 children who have come from varying backgrounds such as losing parents or financial concerns. People are able to visit the orphanage on a volunteer basis to play with the children and help where needed. The children are aged from 2-18 years old and they rely heavily on donations from visitors and from sponsorship of the children. Medical costs of taking the children to local doctors are covered through donations and they require $175 per month. They have designed projects which help to reintroduce children back into their families, and help to develop small businesses for families providing them with income. Donations are also used to help children with congenital abnormalities such as providing surgery for children with a cleft lip or palate. Playing with the children was immensely enjoyable and a privilege. Each child had a unique personality and talents, were well behaved and a delight to be around. I made some lovely friends.

Having taken part in the 'Teddy Bear Hospital' program that was initiated at Keele, a colleague and I thought it would be a good idea to do a similar project with the children of Namaste. We designed some posters, word searches and colouring sheets to teach them about health and hygiene. We taught them about what a doctor is and does, and were able to let them use a stethoscope and pulse oximeter. It was very enjoyable and was also a proud moment as the staff told us that the children can be anxious about doctors so this may help to relieve their fears. Hygiene is an important issue with children and particularly in Nepal with regards to the economic climate, it was a great opportunity to help educate the children about what they should do to keep healthy. Also, as a result of my experience, I have begun a sponsorship program with a 10 year old boy called Ganesh that I met during my stay and intend to visit again very soon.

The culture of Nepal is captivating and I enjoyed sampling the many culinary delights of the country. Religion is very important to people and religious symbology can be seen on every street whether it is a small temple to Ganesh or the eyes of the Buddha.  In my spare time, I was able to visit some of the many beautiful temples dedicated to the Gods and Goddesses of the Buddhist and Hindu religions. One particular statue I encountered was called the Shiva Lingam and represented the union of male and female. Couples who were unable to conceive would visit these statues and fertility rites would be performed.

I was also fortunate to be present for the festival of Shiva and I took part in some of the traditional dancing and rather embarrassingly was called a "moron" by one of the dancers! I don't think my height and shoe size helped me to imitate the flowing steps of the traditional dances! We also took the opportunity to go paragliding, cave climbing, and spent a few days on safari in Chitwan National Park, all of which I would thoroughly recommend doing.

The elective was an amazing opportunity for me to experience medicine abroad and I feel I have made the most of my opportunity. I am very grateful to the consultants for their support and teaching. I learnt a lot about how to be a good clinician from observing their examination and surgical skills as well as their decision making.

I saw first-hand the often striking differences between UK and Nepalese medicine and admired the skills of the doctors that have developed from the lack of resources and technology available to them. The principles and management of patients with common obstetric and gynaecological conditions are basically the same as in the UK. The difference is found in the way that they are applied in Nepal, but still managing to achieve success and positive outcomes for their patients.

I also got very involved with Nepalese culture. I sampled traditional cuisine, visited many temples and joined in the festival celebrations! I came to love the country and despite the obvious poverty that clearly impacts on people, it is a happy nation where people appreciate what they have and are thankful.
 

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