Elective Part II: A foreign country

Now that my Nepali elective is over the medical school has sent me out on the last of my placements as a student. When we all start on black Wednesday this year, the junior doctors will have had a couple of days induction telling them where the fire exits are, how they log into the electronic patient records system and how to lift with your knees and not your back. Then the current juniors will move on and we'll be left manning the wards. My medical school thought we should spend the next three weeks on the ward we'll begin working on in August - so here I am, in Edinburgh, complete with brand new tram(s):

During the short tram trip into the city centre I overheard a child asking their mum continual questions along the lines of "what's that?" and "why?". They got onto the topic of transport. "Where do trains go?" asked the child, "well they go to lots of different places, like Glasgow and Aberdeen and London" explained mum. Not yet fully satisfied the child continued "Where do boats go?" and mum obligingly explained they could go to lots more places, all around the world. "Where do trams go?" asked the child finally, "funny you should ask that" said mum, "they only go from the airport to the city centre and back"...

Milk tea and washing up

My last few days in Kathmandu have been spent sitting in the local coffee shops writing up my elective report, drinking way too many espressos and sampling the range of "german bakery" items that are so common here. I've also enjoyed my last few days of having breakfast made for me (toast, omelette and milk tea by the guesthouse), having my washing available from the laundry man a day after I leave it with him and only having to ask for the bill after dinner - and not worry about the washing up. And by the way my most expensive dinner to date has been 900 rupees = $9 = £5.30 for a starter, main and beer!

The team (above) taught me about surgical techniques, patient centred care, wound dressing, nepali customs and brought me tea on many occasions - the only problem is I've now got used to several spoons of sugar in it. The mobile phone application project I was working on is finished now and there are a few things that we're going to try and change. It's still in a pretty simple form, but if you want to try playing around with it have a look here (only on android at the moment):

Things I will miss about Kathmandu:

• The friendly traveller vibe around Thamel that means you can chat to pretty much anyone. Among others I met a claymation animator, a sanskrit student, a GP from hampstead and the owner of a long running bakery in Kathmandu. That doesn't happen in London.
• Being able to barter the price of mostly anything.
• Milk tea - pretty much what is says on the tin. Milk boiled with tea and lots of sugar.
• And finally my walk to work down this street:

The pass pass

Day two of our mini Himalayan trek: we'd already climbed the height of Ben Nevis and Snowdon, ascended the famous 3000+ stone steps, and checked into a small mountain lodge with plywood partitions for walls. Armed with a trusty guide book, map and advice from a few friendly local porters, we set our alarms for 4:45am the next morning. Safe in the knowledge that should the alarms not wake us, all the other guests in the mountain lodge shuffling their shoes on and securing their head torches would remind us to get up and climb the extra 300m up to Poon Hill for the spectacular  sunrise panorama of the Himalayas.

Early dawn arrived, along with a cloudy haze that advised us to stay in bed. But we still got up and began climbing. The haze thickened, the nearby hills began to disappear and by the time we reached the viewing point, only the viewing point was visible. We took our photo next to the official "Welcome to Poonhill, 3210m sign" and trudged back down for a still early breakfast.

Later, fueled by Tibetan bread and milk tea, we set out on day three of our trek and reached the Deurali Pass (Deurali means "pass" in Nepali, and so the English map name of Deurali pass  translates as the "Pass pass"). By 10am  we could see the Poonhill viewing point glinting in the sunlight across the valley, now with a backdrop of wrap-around Himalayan peaks. Why did we get up at 4:45?!

Reunited

View from the top of our guest-house with monkey temple glowing in the background (strange expressions due to standing still for the 30 second exposure).

 
Tim's story:

Arranged with the guesthouse owner that we'd set off around 15 minutes before Fiona's flight arrived. I came down to the guest lounge and we sat waiting for the driver to appear. 15 minutes passed, then 20, then 30 - no sign of the driver arriving to go and pick up Fiona. Finally a horn sounded outside the building and we were on our way. Then came the mad dash through the afternoon traffic to get to the airport on time - mobile buzzing in my pocket with messages from Fiona saying "I've arrived".

Fiona's Story:

I've finally arrived in Kathmandu! I finished night duty around 10am Monday morning then caught the flight from Heathrow Monday evening. Foruntately it wasn't too busy so I was able to stretch out across three seats and get some broken sleep during which I dreamt I was in a plane crash :s . Changed at Dehli and arrived at Kathmandu 20 minutes early, Breezed throught the visa desk and collected my bag only to discover there was no Tim waiting for me- had he forgotten? I didn't even know the full address of our guesthouse so was getting a little worried but fortunatley my mobile worked we estbalished he was on his way.

First impressions of Kathmandu: Everything I'd heard and read about the busyness, noise and crazy driving is true but it's an amazing place, really fascinating with so much to see. The people are friendly but not pushy as I've experienced elsewhere and the Asmita guesthouse is fantastic. Our room is lovely and the balcony gives great views of the busy streets below and the surrounding hills. It was incredibly hot when I arrived but this evening is very pleasant and we've already been out for some tasty momos. I'm still a little confused about what day/time it is- finishing nights and changing time zones is a littel challenging but I can't wait to start exploring the city properly tomorrow!

A taste of Butwal

Back in Kathmandu now with a few days left before Fiona joins me for some much needed holiday. I tested out my "sound-and-shot" function on my Samsung S4 mini on the bus back from Butwal, so here's a short clip to give you an idea of how the 8 hour bus journey went. It's a picture from my seat in the bus with the background sound attached:

 

If any of you blog readers ever end up going to Butwal, Hill Park is a must see (although all the guide books say "Butwal is a place to pass through"). If you do go, here's what you'll see:

 

Geko's, graft's, ghaa-yee and good hospitality

It's only been two days here in Butwal so the team have got through about 10 operations including Cleft lips, palates and post burn contractures.

Accompanied by the occasional gecko chilling out under the theatre a/c, I was handed the knife several times to take the skin graft for a variety of post burn contractures. Without going into detail, I have to say it's a strangely satisfying experience releasing scarred skin (a little like those of you who ever let pvc glue dry on your skin at primary school and then took pleasure in peeling it off)!

In the afternoon the scrub nurse came up to me and said "curd, curd!". Without explaining that I was in fact from the UK and not the middle east, I followed her to the lunch room and discovered small pots of fresh yoghurt for us all to snack on. Having tried to avoid dairy products for most of my stay so far, I thought I'd give this a go. It was called ghaa-yee (probably not how you spell it) and was both tasty and refreshing in the 40°c heat. A day later and I've neither turned yellow nor developed any d&v: good ghaa-yee.

Today we finished early in the afternoon so I took a walk to the top of Hilltop Park. The heat is bearable if there is wind, and at the top of Hilltop Park there is plenty. There were also plenty of locals going for their afternoon walk surprised to see a white foreigner trailing all the way to the top. Pretty much everyone I walked past called out "where are you from?". In Kathmandu this is the beginning of a conversation that leads to either buying a small violin like instrument or taking a taxi ride, but out here they genuinely wanted to know.

Two traditionally dressed elderly nepali women walked past me at one point just as I had decided that my feet were in need of some exfoliating - I had decided to walk most of the sandy path without sandals. I'm pretty sure our nepali conversation went along the lines of:

Women: "did you walk all the way to the top without shoes?!"
Me: "yes?"
Women: "is it not sore?"
Me: "good, good" (while gesturing towards my feet in a kind of 'its-good-for-my-feet-to-see-the-light-of-day type way)

Anyway, I really hope that's what they were saying...

36 degrees and rising

Just arrived in Butwal 240km west of kathmandu for the next outreach surgical camp to Lumbini hospital. It's 36°C now (at 6PM in the evening) and is due to go up to 40°C tomorrow! Got myself an air conditioned room and a hotel owner that speaks no English. No tourists round here....

Seeking shelter

Now the flowers fall, the wind arrives, the sky ignites and the rain drops. What was moments before a street filled with the cries of stall traders and herding human traffic, becomes a tropical forest of rain spouts and filling pools watched over by the sheltering hoards in neighboring shops. Here, all aspects of the weather arrive at once. The wind picks up, the sky blackens, the rainwater shower head is switched on and there is a crack of thunder seconds away from the sheet lightning. The locals seek shelter immediately in any close by shop front or tarpaulin. Walking quickly having inserted only one arm into my Marks & Spencer cag-in-a-bag, I survived on the streets all of one minute before I was forced to shuffle in behind the counter of a local pharmacy and seek refuge. The rest of my journey home was interrupted by short stays in the local electronics, refrigeration and spice shops. Let's hope this isn't an early start to the end-of-may monsoon season.

Sandal-craft on labour day

On the backstreets through Thamel - some cobbled, some dirt track and some bathed in a layer of water thrown down by locals in an attempt to scold the street for being so parched and dry - my budget no-name brand TK maxx sandals gave way. The insole, to which the sandal straps are attached, detached from the main tread of the sandal leaving me with no defence against the rugged roads. I stopped at a local shop, asked where I could have them repaired and was directed to one of the beggars on the street who I had previously walked past and paid no attention, as is the custom in the streets of London.

The shoe repair craftsman then set about work making holes in the sole of my sandal with an old screwdriver and winding thread between the sole and the straps. His discussed with me how he would go about fixing the sandal, although my side of the discussion involved smiling, nodding and occasionally saying "good, good" in Nepali. After a few minutes work, the sandals which I would normally have abandoned were as good as new.

In a sure footed stride, I walked on to the hospital only to discover that today is the national holiday, Labour day (Majdur Diwas). So I headed back to the hotel and walked alongside the sporadic marches that happen across the city.

Hospital on a hill

This is the distractingly beautiful view from the operating theatre at the newly opened Kirtipur hospital. Throughout the week, half the plastics team works here and the other half at Model Hospital. The plan is to eventually move all the services here, but at the moment most of the burns are operated on here while the clefts and more complex procedures happen at Model hospital.

There's one particular patient I should tell you about but I'll keep it vague for confidentiality reasons. A couple of posts back I mentioned that I had assisted in a 36% burns surgery - the last couple of days I've been able to see how they're doing and help with the dressing changes. This patient was burned in a house fire and unusually attended the hospital pretty soon after the incident. This seems to be one of the issues here; often patients cannot seek appropriate medical help immediately and often will go for long periods of time without any treatment. Sometimes to the extent that they only visit the hospital 10 or more years after the event.

So this patient attended early, had the surgical debridement early and has been fighting off infections and a host of other physiological insults that happen after major burns like this. I'm happy to say that most of the newly grafted skin has now taken, and slowly the 36% of their body surface area that was affected by the burn is healing.

One of their next important steps in treatment is to maintain adequate calorie intake. In the UK doctors and nutritionists will happily scribble on the patients notes for regular fresubin (high energy protein drinks) to bulk up the daily intake. But since this is expensive stuff, the schedule here is lots of milk, eggs and Dhal Bhat "to the max" to quote the senior doctor from today:

 Sounds good to me!

The local music shops

Fixing it for free

Often the first thoughts that come to mind about plastic surgery are: money and cosmetics. This might be true in some parts of the UK and the US, but is far from the truth out here.

The team here is lead by a Nepali born surgeon who chanced upon a career in plastic surgery after observing a team of American surgeons fix a cleft palate. After being trained by them he set up the outreach service and the team has continued to grow. Now there are surgeons, residents (SHO's), speech therapists, nurses and a group of administrators that keep the donations coming in.

We're used to healthcare being free in the UK, but for these thousands of operations a year to be performed for free out here is pretty amazing. Sometimes they get patients to pay around 1% of the actual cost. It seems that if patients pay a little for their treatment, then they take it more seriously and comply with follow up. But the majority of these operations are provided completely free.

I've been trying to steer clear of posting surgical photos, but I thought I should illustrate just how big a deal these free surgeries are. So above is a basic picture showing how a cleft palate is closed - cleft palates and lips form the majority of their work. And below is a sample of four patients I saw the other day each with post-burn contractures. All have now been operated on, and have had full function of their hand/foot returned to them:

 

Impulse buy of the day

In the evenings so far I've been lucky enough to have a couple of other medical elective students to go out for dinner with, but now that they've left for the heights of Everest, I have much more time on my hands. So, after some advice from friendly locals, I bought a guitar.

One of the things that immediately strikes you about Nepal is the people. I experienced this last time when I got lost in the city centre and asked for directions. After seeing that I looked pretty confused by the directions, I was escorted to my destination by the quickest route possible.

So, while I was in a coffee shop at the weekend, I asked if the staff knew where I could buy a guitar. They drew me a map, wrote down the road name in Nepali (so I could show to someone on the street) and recommended at least 4 different shops. So I set off full of coffee, breakfast and toast (from Chikusa cafe) and pretty soon found myself at an intersection with 5 roads spanning out like a star from the centre. At this point I would have normally given up, but I showed my bit of paper to someone on the street, and again was escorted a couple of roads until I was in the guitar shop. After some playing, comparing guitars and negotiating, I got the one above for around $30 (£17)!

Thanks to Lami from the street (at least I think that's what their name was), I now have a shiny (although slightly dusty) new guitar to entertain the guests of the hostel with.

What do you enjoy eating?

As part of my elective project I'm working on a mobile phone app with the team here to help with burn care in rural Nepal. The idea behind the app is a simple questionnaire that can be used to follow up patients with scars. There are a few of these questionnaires that exist already but none take into account the daily function of the patient. So for example if you have a scar over your elbow, then bending your arm is difficult and you may not be able to feed, wash or dress yourself.

So the app is a simple way of asking these questions, with the aid of one of those smiley face scales for rating their pain.

 

The picture below is of a patient I attempted to trial the app on. This 70 year old lady is Newari, and so speaks a completely different dialect of Nepali that none of the team spoke (think listening to Welsh as an English speaker). Luckily their son was able to translate a little, however some of the questions didn't really work.

For example, rating pain doesn't seem to be something people here understand. So when I showed her the smiley faces she just laughed and eventually said no pain at all (she had a scar in her popliteal fossa from a previous burn). But then I moved on to asking "do you need help to feed yourself". I think this was translated as "what do you eat" and so she started explaining in detail all about the rice and chicken and vegetables that she ate, with confused expression on her face. Her confusion grew as I started to ask about "do you need help to wash?" and "can you dress yourself?". Which again were translated as "how do you wash" and "what do you dress in?". Not very useful, but we did have a great time laughing about it.

 

All thumbs

There were several of these cases at the outreach camp in Bharatpur - it's called polydactyly and seems to be quite common over here. It's a pretty simple surgery to correct and just depends on whether the joint is involved. In one of the cases I saw, abductor policis brevis (thumb muscle) was attached to the extra thumb and so it was functional. Useful for playing the piano perhaps?

So in total we operated on 10 cases (mixture of post burn contractures, clefts, polydactyly and moles) on Saturday and another 4 on Sunday before coming back to Kathmandu. The surgeon then arrived back in Kathmandu to operate on Monday before heading off to Nepalgunj on Tuesday. This is another camp in the far west Terai region of Nepal, deep in the malaria zone and with average temperatures of 44 degrees C at this time of year. Best to give that one a miss for now...

Official elective selfie

There are a complex set of road signals I've yet to figure out in Nepal. Many of the highways/roads-with-large-holes in them are the only commuting option for large trucks and buses to get between the main cities, and so there seems to be some kind of system of "here's a good place to overtake" as signaled by the driver in front of you. So an indicating light that would mean "I'm turning left" in the UK seems to mean "danger! don't overtake!". Where as an indicating light for turning right means, go ahead and overtake. This is only the beginning. While performing the overtaking manoeuvre there is another set of headlight-flashes and horn-honkings that take place aimed at the vehicle coming towards you on the other side of the road. They reply with a similar set of morse code honks and flashes - and in the end it all seems to work quite well.

On that note, above is a selfie of the team I traveled to Bharatpur with. And below, what we were looking at through the windscreen at the time (possibly explaining my odd expression):

 

Every trip should start with Momo's

Surgery safari

I'm sitting just below this map of the plastic surgery outreach camps waiting for a long and complex operation to finish before we head off to the closest camp in Bharatpur. It is around 150km south west from Kathmandu (the closest pin on the map) and is right next to the Chitwan national park, where the elephants and royal bengal tigers live. It's not so much a surgical outreach "camp" but more like a team of surgeons visiting another hospital in a nearby city - according to wikipedia it has a population of 143,000. As far as I understand, there are local "scouts" in each of the areas on the map whose job it is to round up suitable patients for surgery. Then the team (one surgeon and one scrub nurse) arrives and they work their way down the waiting list.

The trip was planned (as much as "planned" happens in Nepal) for yesterday until Monday, but then there was an ameloblastoma to operate on. This started at 10am this morning and is still going on at 1715 - they are about to start the microvascular anastomosis so it's likely we won't leave for a while yet!

Time for a nap on the consulting couch...

 

View from inside the microbus

Socks and Sandals

Today I visited Kirtipur hospital, a newly opened building around 5 km south west of Kathmandu. The hospital has only just opened, but there is still work going on inside and scaffolding on the outside. Compared with the hospitals in Kathmandu this one is a brand new western style hospital.

There were lots of photos that I could post from today that would probably be inappropriate for most of the internet. And I know there are a few reading that probably don't like the sight of blood (lets just say there was lots). So I thought I'd post the photo above. In theatre you wear sandals and most people take their socks off as well. Today I decided to keep them on and now realise why its a good idea to take them off. I got to assist in a burns case today (36% burns around a week old) and was shown how to debride the wound. However, at one point there was a lot of "fluid" flowing onto the floor which soaked the surgeons feet standing next to me and narrowly missed mine. Still undecided about whether I need to dispose of my socks now.

Maybe I need to bring back-up socks with me each day?

Namaste from Kathmandu

Namaste from Model Hospital Kathmandu (which is neither very small, nor only for models)! 

So this is going to be my main home for the next few weeks. It's a large hospital in the centre of Kathmandu run by a non-government organisation and provides all the major hospital services (A&E, obs/gynae, general medicine, paediatrics, neonatology among others). But the team I'm with is the Plastics team. They operate mainly on cleft palate, post-burn contractures and other maxillo-facial patients. The same team operate out of another hospital 5km west of Kathmandu where the majority of burns work is carried out. They also provide monthly outreach camps to rural areas of Nepal, and this work is performed for free.

It's early days yet so I'm not sure when/where I'll be visiting each of these places, but for now I'm just soaking in the sights (think dust) and smells (think incense mixed with a hint of sewage) of Kathmandu.

Salaam alaikum from Muscat, Oman

Please arrive 3 hours before your departure time

I'm currently sitting in the airport waiting the recommended 3 hours before departure time for international flights and wondering why I came so early? When I arrived at the check in desk earlier there was a large queue for "economy check in" and zero queue for "web check in". I waved my printed out ticket in the air and was ushered to the first available desk. "Do you live in Kathmandu?" said the check in clerk. A little confused I started telling him all about the fact that I was off on elective, had even got my visa prior to departure and was staying for 6 weeks. Immigration and police officers must get this all the time. Ask a simple question and the passenger thinks they are being quizzed in order to find out if they really are who they say they are. In fact, he was only checking that I hadn't forgotten to print out my return ticket.

10 minutes later I've cleared security and have been left with a world of time to explore the world of duty free and their sampling whiskeys.

Last minute cheques

So, welcome to my blog. I'm heading off on elective soon and I know that many of you want updates, so my plan is to post interesting photo's and stories as often as possible.

Keep in touch and follow the blog by adding your email address at the very bottom of the page.

ps- the funding finally came through for my project (only around a month late). More about the project in another post...