Journal of Elective 2004

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Saturday, July 10, 2004

Day 3: Time to be a Tourist

Last night was another one typical of the hospitality here. We had a great dinner of rice, spices and vegetables, followed by much entertainment as we all - the four students here plus Bishop’s nephews and nieces - played circle games. My disappearing hankie trick also made an appearance.

Today we visited Bhaktapur - a small town that has been gobbled up by expanding Kathmandu. It’s very touristy inside, but that wasn’t a problem and there was much to see. We also brought medicines from Bishop - plus a couple of peak flows and a Lec Notes in Paeds - to the local hospital and after contacting the director, he arranged for his colleagues to give us a tour of the city, ending in the hospital.

Today we also saw many other aspects of Nepali life. This isn’t meant to sound sensational in any way, but some of the street scenes were a world away from those in the UK. And yet again the kindness, hospitality and friendliness (?and tolerance) shown to us was out of this world. More than we deserved too, as we were simply acting as the messengers for bringing the medical supplies from Kanti Hospital.

I should explain who “we” is! There’s three other students staying with Bishop. Tou Pin is also a med student from Glasgow (and Malaysia). Pam is a med student from Germany (here for several months) and Ashley is a journalist student from America. Having such a range of backgrounds makes life very interesting and it was great fun to explore Bhaktapur and interpret the signs and culture together.

I’m really glad about the way I’ve adapted to the way of life here... a way which I really like and am pleased that I’m only 3 days into a 5 week stay! Showers are one example, as so many are solar powered. Yesterday I was close to facing a morning “shower” in the form of two Boots’ antiseptic wipes!!! But fortunately water returned, albeit cold.

I also realise how much I was fleeced for money when I arrived, thankfully shortlived and in practice a small amount in UKP terms. Today we got a taxi to Bhaktapur - half an hour away from Kathmandu - and the total cost was 250 rupees. That’s about 2 quid, or 3-4 dollars... to be split between the four of us. I paid a similar amount to get from one district to another in Kathmandu on Friday morning! Well done to that taxi driver.

Now I’m about to head back to Bishop’s for dinner. No doubt tonight will be equally full of hospitality and good food. Great for setting me up for the Sunday-Friday working week that I will experience from tomorrow.

Namaste from Kathmandu!

Sunday, July 11, 2004

Day 4: Palpation and Auscultation

No, not the name of a new film, the story of two superhero puppies conquering the evil cat kingdom, but the two most important skills for doctors in the outpatient department (OPD) in KCH.

Today was my first real clinical experience at Kanti, starting with several days in the Cardiology Unit. I went with one of the doctors to the outpatient department and sat through consultations for 2 hours. Not so very different to OPD in Yorkhill Hospital you may think. But then in Yorkhill the patients wait outside the room for their appointment, haven’t travelled huge distances in cramped transport to get there, and don’t have to pay for the privilege. Medical OPD consists of a line of 7-8 cubicles, with a doctor in each of them and scores of families waiting inside and out. Then there’s the main hall where more families wait to be seen, and opposite is a similar line of cubicles for surgical OPD.

The result is a very noisy, hectic and often interrupted series of OPD consultations. Which is actually fantastic for students to experience a wide range of clinical signs.

And that’s where Palp (using the hands to feel e.g. the tummy) and Ausc (using the stethescope) come in. They’re the two examination methods (along with inspection and some percussion) that are used to screen out the severe cases from the less-severe. If the child doesn’t have an enlarged liver or spleen; has present (and roughly equal) femoral and radial pulses; doesn’t have lymphadenopathy (enlarged glands), cyanosis or pale conjunctivae, then the chances are that the condition isn’t too serious. The art of the medicine also comes into play when listening to the heart - some murmurs are normal, some are mildly important and others are very serious. I heard all the main ones this morning - delayed S2, atrial/ventricular-septal defects, patent ductus arteriosus - they were all there.

The doctor who I was with was inspirational. I don’t like to write too much about individuals on this online diary, but he has been fantastically helpful to me, providing constant motivation and interest in making my time at Kanti useful to both myself and the hospital. Including the disappearing hankie and balloons!

We also used one of the peak flow meters for the first time today, and the appearance of it caused similar excitement that a new MRI might cause in the UK. So for a short while after the OPD I ended up explaining centile charts to one of the technicians (who had limited English and 10 minutes... but great fun tearing up bits of paper as a learning aid!).

But amidst all this excitement and eye-widening experience was again the shortages faced by the hospital. If you’re reading this and are coming to Kanti yourself, please do get in touch as I can give a good idea of things to bring. I hope to provide a “wishlist” on this website once I’m back in the UK. There’s loads of small things which are easily begged/borrowed/stolen from hospitals at home, and there’s also a great need for expensive things like echocardiography machines.

As for the children themselves - they display the most patience and best ‘behaviour’ I’ve seen. There is a limited play service available here although this is another aspect about which the doctor I was with is keen to expand. Tomorrow I’ll see - and hopefully do more - in this area.

Finally, an apology. In my haste to write I made a mistake with my description of Bhaktapur... in fact it’s definitely not a part of Kathmandu (even though the boundaries are closing in) but a separate city of the Kathmandu Valley!

In the meantime, it’s nearing the end of another fantastic day in Kathmandu. Namaste!

Monday, July 12, 2004

Day 5: The Hot Shower God

American cuisine hit Kathmandu last night, when Ashley prepared a fantastic meal of sweetcorn, barbecue chicken and spicy baked beans. It was quite funny how the family were puzzled about how to use BBQ sauce, compared with the usual situation with us struggling to use our fingers to eat in a half-civilised fashion!

This morning the Hot Shower God must have been busy as my requests last night weren’t granted. Instead the “More Tepid Than Freezing” God must have answered as that’s the kind of bathing experience I had. Thankfully, the Hot Shower God was back to normal function this afternoon.

I was really looking forward to today, which promised a ward round with the really enthusiastic paediatric cardiologist who I met yesterday. However, frustratingly I had to leave the round quite quickly as I felt like I was about to pass out. I’ve got no real idea what it was... jetlag combined with new germs, the Kathmandu pollution and perhaps dehydration. There’s no drama, just that I don’t want it to happen again tomorrow as I am keen to learn in this ward.

Instead I went round with Bishop to deliver more of the supplies which were brought across - books to the library, peak flows to lots of different wards and some colouring pens to the play service. We also had quite an in-depth talk with the doctors in the Oncology Unit - where a lot of Bishop’s fundraising money goes. It’s impossible to state the “normal” cost of a child who comes to Kanti for cancer therapy, but it’s at least $4000-5000 on average. Loads of money, and so needed too.

After lunch with two of the latest students (both from Canada) to spend time at Kanti, Bishop and I went to the UK Embassy so he could sort out some things. I waited in the entrance hall and found a equally-bored and equally-balloon-loving wee girl. So a flower pot and sausage dog later we were both slightly happier. I admit to being a bit concerned that if one of the balloons was to burst, the sound might be mistaken for a gunshot, with half the SAS troops storming in. However, the embassy is the only place where I’ve been aware of security and any political consideration, normally there’s no sign of that in Kathmandu at all.

Post-embassy, we headed into Thamel and I was shown loads of smaller unfound places as well as the big favourites like Tom and Jerry’s Bar. I nearly equalised at pool with Bishop but alas he beat me 2-0. However, the table had more peaks than the Himalayas!

Thanks for all the emails I’ve been receiving - really great to hear other news and keep in touch.

Enough talk. Tomorrow is getting near. I’m looking forward to it already. Namaste!

Tuesday, July 13, 2004

Day 6: The Importance of Fun

It’s been another great 24 hours. Yet more fantastic food was enjoyed last night, courtesy of our “2^nd mum” Rama. Then great family time with the Joshis (+ neighbouring kids and relatives) and us students finding entertainment with puzzles, conversation, learning Nepali and also some juggling which I brought over for the hospital.

The good night of sleep which I needed was achieved, and today it was “Take 2” with the Cardiology ward round - which was also achieved successfully! The cardiologist (the enthusiastic one, see below) insists on all clinical teaching conversations to be conducted in English so I can understand what people are saying, and partly for the students too - all Nepali doctors are required to speak English. Just another example of the hospitality I have experienced here. After the round we paired off, and I was assisted in translation when I went with one of the Nepali-origin Chinese students to take a history from one of the patients. We did this, taking a little longer due the translation required... but with unbelievable co-operation and patience from the grandfather and 9 year old boy. We presented this to the other students + Dr, and got some excellent feedback and teaching.

After lunch of Momos (plus discussion of our plans to visit Pokhara this weekend) we went back to complete the examination of the patient. He was so co-operative that we did just about every examination possible, interspersed with some juggling. I learnt from Shaq (medical student from China), and I hope he learnt something from me. It’s interesting how some aspects of history/examination are so similar, and others are so different.

Then... time for balloons! I must thank Ian, my “balloon coach” for his top tips in dealing with large crowds of kids, especially in avoiding disappointment and losing their interest or patience. I did one flower-pot (requiring 4 separate balloons) before reverting to the much quicker dogs, parrots, airplanes, swords and radon guns! Perhaps I can even suggest that if UNHCR or WHO are looking for a way of ensuring maximal turnout of children for vaccinations etc, perhaps balloons are the answer. Within a few minutes the scale of the operation became clear and word soon spread to nearby wards! I think total count was about 30 models in 15 minutes!

Academically speaking, the day has been fun and really interesting. I’ve been able to clarify heart murmurs, learn about the differences in presentation that several weeks can make and become well acquainted with the clinical investigation of rheumatic heart disease, tuberculosis, infective endocarditis & Giardiasis.

Mero nahm David ho. Namaste! (My name is David. Goodbye!)

Wednesday, July 14, 2004

Day 7: Rabid Dogs

Last night was an interesting one. I wanted to do some printing at 10pm and so had to find an internet cafe. Having been told they would likely be open at that time, I ended up walking the much quieter, much darker and much eerier streets of Kathmandu. Just 5 minutes round the corner, but an amazing contrast from the constantly busy, horn-peeping, car-dodging, dog-stepping-over of the daytime. To be honest there was still some dog-stepping-over, even more cautiously so as you wouldn’t want to touch the rabid, flea-ridden, coat-matted creatures with a Leki Makalu walking stick (modern day barge pole)! Mission wasn’t accomplished, but interesting to experience the eeriness all the same.

Today was another on the cardiology ward. The round was nice and brief, catching up on any changes since the previous day - as the doctor had to head off to OPD soon afterwards. We took another history (another case of Rheumatic heart disease) and the differences from the UK were the malnutrition, lack of parents, extensive trials of chinese and herbal medicine, and of course the language barrier. Again I was indebted to the Nepali medical student who acted as translator.

OPD was extremely busy so I went back up to the ward. After following up some patients, I brought the balloons out again, with a similar response to yesterday. It was also a good opportunity to get some photos, and Pam also popped up and lended her excellent photography skills. She has a digital camera and so I’m hoping to get some shots on here by next week! So far - swords, aeroplanes and radon guns are the favourites.

I met up again with Pam, Tou Pin and Alex in radiology as per our plan for lunch. However, we were “invited” to observe a pericardial tap. This involves removing fluid from the space between the heart muscle and the surrounding pericardial capsule. I think this is normally done in the UK under General Anaesthetic, or certainly with much local. Hmmm.... in this case there was some IV diazepam given a few minutes beforehand to give mild sedation. On top of this, the room was filled with student and staff observers... extremely daunting for the 10 year old child on the receiving end of this traumatic procedure. Several of us volunteered to leave to make the room less crowded.

However, I had a conversation with the radiologist next door, who was very interested in how it contrasted with UK medicine. I mentioned the fact that play therapy is becoming much more recognised as an essential part of paediatric hospital care... brought to mind by one of the presentations I saw at the RCPCH in March (talking about having ‘on-call’ play specialists for Emergency Departments... I can tell you my views on that another day!). He was interested, and so I offered to show him what I meant with the limited experience and limited supplies I had brought with me to Kanti.

So to next door I went again, this time with juggling balls, balloons and hankie. The distraction from all the goings-on was beneficial to some extent... but realistically it was last-minute and couldn’t take much away from an extremely painful and traumatic experience. They’re really interested though, and the plan is that I will visit tomorrow or next week to do some more. I don’t pretend to be any expert on this though, so any top tips via email/the comments board would be appreciated!

This afternoon we went to Bouddhanath Temple in northern Kathmandu under the expert guidance of Bishop. 3 girls from Malta who arrived recently, also joined us for the trip, and we got there by typical Kathmandu minibus... another new experience! It was another good end to a busy day, and again I find myself finishing this latest entry prior to heading back for dinner.

There’s more pollution now and it’s certainly noticeable at the back of my throat! More reason to look forward to our trip to Pokhara on Friday! Next week will bring a night (Wednesday) with the only on-call doctor for the hospital so I think it’s guaranteed I’ll see loads of procedures then. It’s great how such requests are enthusiastically arranged - they’re even hopeful of finding a bed for me. Whether I’ll get to use it is another question!

Signing off. Namaste!

Thursday, July 15, 2004

Day 8: The System

Day 8, and I’ve now been in Kathmandu for a week. It’s flown by, but with an awesome amount of new culture, rules, environment and living style.

Today I was in Cardiology again, with little change in the patients and with ASO, ANA, CRP, ESR and typical antibiotic regimes engrained in my mind. You do get quite attached to some of the kids, especially in that trust has been built up and I no longer feel like the stranger I used to be. Even recognising parents when walking the corridors, and passing a friendly “namaste” (with hands together, like praying) is great.

But some of the frustrations of working here have also become apparent. Many of the doctors are striving to do the best they can with very limited resources - and while they work in Kanti in the morning, some go onto much more lucrative private practice in the afternoon. I’m sure the day-to-day contrast must be very striking.

I’ve had several interesting conversations with the Nepali students, particularly today actually, and it is clear that there is much more to the way in which ‘the system’ operates than meets the eye. This is a challenge for everyone who lives here, but I hesitate to comment further as I still have a very loose grasp of the situation.

Tonight is party time though, with as many students as we could muster meeting at 7pm for dinner and drinks. How this will combine with our 6am bus to Pokhara tomorrow is yet to be seen! (NB. There have been various stories about the safety of travel recently - we’ve taken lots of advice from the doctors and students, and it all seems to be fine).

I think I’ll miss the hospital over the next few days, and be curious to find out how some of the children have been. However, it’s important to see other areas of the country, and this weekend looks like being an excellent opportunity to travel.

I’m sure internet access will be super in Pokhara, but I may be so distracted enjoying the scenery (and local produce) that the next update may be Monday.

Namaste!

Saturday, July 17, 2004

Day 10: Amazing Time in Pokhara

Hello!

Day 10 and namaste from hot and sticky Pokhara!  So much has happened in the last 48 hours.  I’m battling with a slow computer but will try to describe the important bits.

Thursday evening was great - at least 15 students turned out for the big night, and Bishop took us to a fantastic restaurant in Thamel for much food and alcoholic liquid.  It was great to meet so many people from so many countries, and I’m sure we’ll do it again soon.

I also had my first bike ride through Thamel, courtesy of Shaq (one of the Nepali students studying in Beijing and back at Kanti for summer).  It was white knuckle at some points, due to the potholes of Thamel and me bouncing around on the back-wheels suspension, but a classic way to travel anyway!

We staggered home, helped by a taxi and had about 4 hours sleep, before catching the 6.30am bus to Pokhara.  The combination of late drunken night and early windy bus transport wasn’t the best of times, but it worked, and any notion of sleep was blown away by the amazing scenery en route.  We got to know people’s body odours very well, with the bus fully booked by at least 25 other folk, for 8 hours through hot conditions.  We climbed quite high and descended quite low - as judged by the changing pressure in my water bottle!

The most scary bit was when we passed a crowd who were busy winching up one of the buses which had unfortunately lost the road and descended down the side.  However, we gladly made it to Pokhara by 3pm, and as predicted were besieged (literally) by at least 20 taxi drivers wanting our business.  There were 6 of us together - great for travelling especially as we all get on really well - of Tou Pin, Alex (Cambridge),  Pam (Germany), Annie and Kelvin (Canada).  Alex even managed to get an auction going, to find the cheapest bidder.  It was complete mayhem and at first quite fun, then more tedious as we tried to get out the bus station!
Annie had checked in advance for accommodation recommendations, and we found a fantastic place called Sacred Valley Guest House.  The owner is actually from Edinburgh, although she’s travelling Europe at the moment.  But it is fantastic, with really spotless large rooms, hot showers, a balcony for each room and we pay about 2.40 UKP per twin room per night.

My time is running out... here’s a snapshot of the other things!

• sipping cocktails in a great bar overlooking the lake and Annapurna rang
• eating Nepali dinner whilst being entertained by a live Nepali band - who later agreed to let me play tambourine and bonga drums with them
• being woken at 4am by an earthquake (radiating from the Pakistan one as reported by the BBC) - mild but kind of scary and cool at the same time
• going up a big hill to see a temple whilst avoiding the leeches
• paddling canadian-canoe style across the lake to get to the hill

Right, time to go!  Thanks again for the emails and comments.  Hope all is well and sorry this has been rushed.  Pokhara is fantastic and even better for the group we’re in.  Plan is to stay until Monday am.  Pictures will have to wait a bit I’m afraid as there was a small problem in getting them transferred whilst in Kathmandu.  There will be tons on my return though!

Namaste!

Sunday, July 18, 2004

Day 11: So Lucky

As this evening comes to a close, I will look back at this weekend as one of the best I’ve ever had. Every evening has been full of entertainment, eating out and pool/pub conversation till the wee small hours. Every day has been full of new experiences... challenging at times but so enlightening and so much fun.

On Friday we met a guy who was setting up an orphanage in Pokhara... he agreed to show us round and so we met him this morning. He’s originally from Tibet, and so he showed us the Tibetan refuge where 800 Tibetans live, work, learn and play. It was a great insight into the problems that the Tibetans have had to face, and he was extremely kind in showing us round with such enthusiasm and humility.

He also took us to Devi Falls - an amazing place where the lake “drains” into a single river to disappear into an underground cavern... the result during the monsoon (i.e. now) is masses and masses of water cascading dramatically down a big hole in the ground - more impressive than I can describe. Umbrellas are a must!

Also on Friday we came across two boys who had a written note asking us for a football. Initially we were wary of such a plea being linked to the scams that are well reported, but then again no childhood can be complete without a football!

It transpired that there were four boys in the group, all were street children and orphans who refused to go into one of the nearby orphanages. So today we found a football whilst shopping in the Pokhara Bazaar, and took them for a game in the nearby park! Their faces lit up when they realised we were keeping our promise of giving them a football... it was also a very humbling and interesting time for us as we learned about how they survived every day. Sometimes they didn’t eat for 5 days, and it was clear that they were well adapted to their street environment.

So the international language of football kicked in, and we had a fantastic game, soon joined by other local kids. In the end we must have had 11-12 per side, and we spent the rest of the afternoon playing in the cool heat of the afternoon - much nicer than the humid, hot weather of lunch time!

Between us, we also decided to give them dinner - it was just so compelling to do something when - as a large group - we were so able. So full curry and rice (what they requested) was what we ordered for them... and between the group of us it cost less than 50p each - including drinks for us all and chocolate for them at the end.

Now we are about to head out for our last night in Pokhara. Tomorrow we plan to rise at 4am to catch a last glimpse of the Annapurna range - if possible - before the clouds descend for the day. Then we’ll head to the bus station, to return to Kathmandu.

Pokhara really has been a holiday in itself, and made all the more enjoyable because of the cameraderie (and safety in numbers) of being in such a large and friendly group. My photos will hopefully give an indication of this!

Namaste!

Monday, July 19, 2004

Day 12: Long Bus Ride

Well, back in Kathmandu now after a long day of travelling...

Last night was a good last night in Pokhara.  After a group Chinese meal Alex, Ashley and I waded (literally, up to our ankles) through torrential monsoon rain to get to our favourite bar - ironically called Monsoon - for a last drink in the town.  As Alex and I sipped at Famous Grouse, the rain got heavier and heavier, and a leisurely hour later we conceded defeat to the increasing monsoon outside.  We were also concerned about the possibility of landslides for today’s journey.

The way back to the guest house was very scary - we noticed two dark shadows sheltering from the rain but clearly with guns - they were the soldiers on guard for the palace which the guest house was opposite.  During the day we’re used to a high military presence, but there was something particularly eery about the darkness (there were no streetlamps), the torrential rain, wading back through the streets with two gun-clad figures observing our moves.

This morning we slept in.  So in a fire-drill-sort-of-kind-of-way we fled the guest house to catch taxis at haste for the bus station!  We made it in more than enough time, thankfully.

We were treated to more fantastic views along the weaving main road from Pokhara to Kathmandu - with the usual eyes-closed-is-best approach when the bus was negotiating its way along unbarriered routes high up.  However, the way back was also longer, with an additional 2 hours waiting outside Kathmandu in a long queue for the check point.  We’d passed several already (only Nepali people have to get off the bus - Westerners are exempt which makes it kind of a two-class system) but the queue for the Kathmandu point is notoriously long.  The journey time was 10 hours - a long time to spend in a bus.  Thankfully we didn’t have to adopt the foetal position as with the opposite journey - paying 300 Rupees (= just over 2 UKP) instead of 250 gave us extra leg room!

And now I’m tired, and looking forward to a good meal with our host family and sorting out my stuff for my return to the hospital tomorrow.  And also dealing with my trek shoes, which have been emitting a highly noxious smell since the wee hours of this morning.

Namaste!

Tuesday, July 20, 2004

Day 13: A Grilling

Yesterday’s entry really was under the influence of sleep deprivation, so sorry if I waffled!  Much sleep has been had since.

Today we awoke to a strike... though the news last night wasn’t too clear about how much it would impact on the day’s services.  Kathmandu certainly seemed to be less polluted, and there were fewer cars on the road, but for much of the day it was business as usual at the hospital. 

However, there seems to be some increasing tension in the city, especially with the latest incident when the Maoists kidnapped many students and teachers from a school in the outskirts of Kathmandu.  This sort of thing happens fairly often (so I’ve been told) in other parts of Nepal, but the latest school to be targetted was closer to the capital than before.  There was also more of a military presence on the roads, and at several junctions I noticed that a gun (albeit in the relaxed arms of a soldier) happened to be pointing towards our taxi... and that’s just a bit disconcerting.

Today at the hospital I changed to a different unit, and I was keen to remain with the same group of students. who’ve given me a great Nepali welcome.  This group includes Shaq who read this diary recently and was dismayed not to find himself mentioned personally.  So, Shaq, I hope you will now forgive me!  Shaq, who’s name is Shaq, (Shaq is a medical student from Nepal and studying in China) has been really helpful and patient in helping me take histories from the families at Kanti.  It must be a tedious task with constant translation, but he says he learns from it too so I hope that’s the case.

And so I moved today to the surgical ward, and the round includes the burns unit too.  The turnover in surgery is a bit slow just now - apparently two of the surgeons have gone missing, but I’m sure the real reason has been lost in translation.  Anyway, it means that there are kids who’ve been in the ward for some time, and more who are waiting patiently.  Burns Unit meant seeing children who’ve cried so much they’ve lost their voice, and husky shrieks are all they’ve got when it comes to the extremely painful removal of dressings each day.  The cause of burns is similar to the UK (and the doctor was interested to compare this) - especially in the under 4s where boiling water from tea/coffee and pots pulled from cookers are to blame.  In Nepal it is only slightly different, with large pots of boiling rice being a common cause.  I understand that there has been some liaison with a burns unit in the UK (perhaps at Alder Hey?) but even so the care of wounds remains difficult.

Then to OPD with more surgical problems.... typically paediatric and hydroceles & hernias were the order of the day.

Later in the afternoon I went back to do some “Emergency Medicine” although this was remarkably like OPD as the majority of children had fevers, large livers and dehydration.  However, I was soon asked to do some proper work and present some patients... the doctor there gave me a good grilling in the causes of fever and how to investigate it, but soon realised that my knowledge of Typhoid was relatively low (despite trying to learn about it before coming here!).  However, that kind of teaching is my favourite - you’re forced to think on the spot and the fact he was filling in the forms while I suggested clinical tests made it all the more real.  I hope to do more of that soon.

And now I’m in an internet cafe in Thamel, wondering whether it’s tonight that Ally and her friends come from Glasgow to start their volunteering in a remote part of Kathmandu.  The proprietor of Hotel Red Planet denies having any booking even though I thought they were staying there... but hopefully I can track them down soon even if it is to ensure they’re not taken for a ride (in the metaphorical sense) by the taxi drivers! 

Tonight is Utsav’s 20^th birthday - the son of our host family - and so we plan to celebrate accordingly.  It should be a good one.

Thanks again for all the messages... glad to hear that people enjoy reading the entries.

Namaste!

Wednesday, July 21, 2004

Day 14: A dilemma

You have the tools to carry out a relatively simple operation to repair an inguinal hernia.  The 4 year old with the hernia has been waiting in the hospital for several days.  This wait is accruing the family costs and time from the rest of their family at home.  But there is no anaesthetic available.  What do you do?

This is the dilemma I witnessed this morning.  It turns out that in fact the surgeons have indeed disappeared (see here for a similar story in 2002).  There is one surgeon left, but I’m not sure of his position, and I get the impression he does not usually take the lead in operations, and is still gaining experience (apologies if this is not the case!).  In addition there appears to be an absence of the anaesthetists too.  The answer to the above question, for this morning’s case, is that the short-term excruciating pain is worth it for the long-term gain.

Shaq and I entered the small “minor procedures room” whilst the operation was going ahead.  Four people held the child to the table, and the father kept his son’s eyes closed in a bid to hide the goings-on.  The child writhed around in severe pain, whilst the surgeon meticulously and skilfully carried out the procedure.  Cries turned to shouts for mum, and “they’re trying to kill me” - articulated in a way that suggested he really thought so.

But it would be wrong to stand there from a “western-point-of-view” where anaesthetics, play specialists and the best medication would be available, and criticise, over-compare or offer artificial sympathy.  This is the real situation and the doctors have to battle between their duty to heal and duty of non-maleficence - to first do no harm.

The rest of the morning was filled with a visit to the Oral Rehydration Unit - basic but essential, and the Burns Unit, which I hope to spend some more time in, perhaps tomorrow.

This afternoon I solved the pongy-shoes problem with the expert advice of Shaq, who took me - by motorbike - through Kathmandu to an excellent-value market next to Durbar Square.  1400 Nepali Rupees (= just over a tenner) for a pair of fairly decent trail shoes.  Since the weekend I’ve been wearing hike boots to the hospital and changing to Teval sandals, which becomes tedious.

Tonight I am on duty with the on-call doctor.  There’s no spare room for me to sleep, so I’ve been given the keys for the Cardiology Conference Room - thanks to Dr. Basnet!  Hopefully though I won’t need it too much as I want to see loads of things, especially in Emergency.  Whether I’ll do 36 hours without sleep is another question, but I am fairly keen (and expected) to be there for the ward round at 9am tomorrow.

At least I’ll be out of the Kathmandu pollution which has caused a raging sore throat for the last few days!  I think I’ll have to suck several exhaust pipes every day when I’m back in the UK to avoid petrol-fume withdrawal symptoms.

Namaste!

Thursday, July 22, 2004

Day 15: Early Report

I write this entry from the observation ward of Kanti at 4.30am in the morning (for transcribing to the blog later in the day!).

I’ve seen lots of patients come into the Emergency Department, and listened to chests, tummies and looked at x-rays. However, at 3am I went up to the ward where I was supposed to have a room, to discover that despite having a room key, the ward itself has been locked. Plus it’s impossible to attract the attention of the nursing staff especially as making lots of noise wouldn’t really be acceptable at 3am! C’est la vie!

And so I find myself back in Observation, passing the time by reading Lonely Planet and planning my next moves. I’m surrounded by 10 beds. On each is sleeping two children and two parents... from different families. Remarkably all is quiet, either due to sleep or respect for those sleeping.

It’s a unique time to think, observe and reflect whilst in the epicentre of Kanti Hospital. Tonight I’ve had a fascinating discussion with one of the doctors about Nepal’s political, social and health situation. It is said that anger and frustration are the most revealing emotions, and so I have learnt a lot tonight.

Again I’ve experienced hospitality that is more than I deserve. The 3-strong team in Emergency - one medical office and two interns - became more and more helpful during the evening. On my reluctant admission that my dinner had consisted of 6 digestive biscuits, they promptly insisted that I go with them for dinner, even though the food had to be shared out between 4 instead of 3. We talked about so much, including The Beatles, Beckham, Rochester and Moscow. Very random.

The silence is broken by a new arrival to the ward - a crying infant whose parents look distraught, tired and embarrassed about the commotion on the ward. They search for a space on a bed, but it’s as tight as it can be. A corner is found and they attempt to calm their charge. More people rouse, understandably disgruntled by the interruption, but then again this is a working ward and the parents doe their best to improve the situation.

Tonight has been another rich new insight.

Friday, July 23, 2004

Day 16: A Great 24 Hours!

The last 24 hours have been fantastic. I returned home yesterday at 2pm feeling really tired - probably due to having been up since 7.30am the previous day!

But a short snooze later, I met up with Ally and her friends from Glasgow Uni. I didn’t realise that there are actually 18 volunteers from SVA coming over, and 12 of them have been in Kathmandu for the last few days. On Sunday they go to a training camp for a week, then head to Ilam for some serious building and teaching.

We tried to go to Alice’s Restaurant, but it’s closed down. So we went to a slightly-American place and then for drinks in Tom & Jerry’s. Brendan, one of the students, seemed to inspire the restaurant staff in making their standard lights give a glitter-ball effect... slightly nausea-inducing but great initiative all the same!

Thamel, the district where most of the tourist facilities are, was busy with students at Kanti too, and we met quite a few en route. The evening ended with quite an angry taxi driver taking me a break-neck speed through Kathmandu at half midnight, with no other traffic on the road. We got a bit lost, but I recognised the area and so got out and walked the short distance back to my abode.

This morning we all joined up again (Ally’s group, the med students staying with Bishop and Alex) for breakfast at Helena’s - which boasts the highest roof-top garden in Kathmandu. And so we breakfasted surrounded by Kathmandu and the hills around it. The main attraction was the set breakfast of eggs, toast, potatoes, banana fritter and tea/coffee for 65 rupees. That’s less than 50p.

I showed Ally’s group around the hospital, and they seemed to find it an interesting experience - perhaps in anticipation of what they might find in Ilam. And then good news - the operating theatres were back in action and I saw a whole load of paediatric surgery from hydroceles to repair of gastroschisis.

I’ve just had lunch and will be back at Kanti to work with Shaq in the Emergency Department again - it’s great for seeing loads of things and attempting to diagnose conditions. As always, Shaq is great with the translation, which is a huge huge help.

And then to one of the bars in Thamel, where we’ve all decided to meet up. Should be a good one again!

Namaste!

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