Bistari, bistari 2.0 - A second trip to Nepal - Manthali Volunteering

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Volunteering at Tamakoshi Hospital in Manthali

April 4 - 16

After months of trawling the internet looking for a volunteer nursing opportunity that seemed legitimate I happened upon Rural Assistance Nepal (RAN). They provide resources to a number of medical and educational facilities.

http://www.rannepal.org/

Some email correspondence ensued and an opportunity to spend time at Tamakoshi Hospital, a small hospital in the east of Nepal, emerged. The hospital was established initially as a health post in 1986. In 2000 it became a 10 bed hospital which has now expanded to 15 beds. The hospital provides in-patient and out-patient health services including reproductive health, family planning, maternal and child health, pathology, ultrasound, ECG, X-ray, primary dental care, primary eye care, 24-hour emergency, pharmacy and ambulance services. The hospital has a team of 20 health staff including one doctor, health assistant, staff nurses, auxiliary nurse midwifes, community medical assistants, lab technician, lab assistant, ophthalmic assistant, dental assistant and a pharmacist. The hospital sees over 24000 patients each year and charges a nominal fees on its all services. They also provide many health and dental camps throughout the region. It's truly a great healthcare provider!

We paid for a jeep to get us there, it took about 8 hrs (with a stop for noodles) to get there from KTM. Arriving late afternoon we were met by Dr Suman, the Medical Administrator and chief doctor, who in turn introduced us to the staff. In my correspondence with Dr Suman prior to our arrival I had asked if there might be some work that Mary could do in the line of English teaching/conversation. From these emails Dr Suman decided Mary was an accredited English teacher and despite numerous attempts to tell him otherwise Mary became an English teacher! We both had to introduce ourselves and give a short speech (eek) from that point on we were warmly embraced as "expert nurse" and "expert teacher"! Next stop was our room- one in a block of 4 adjoining rooms 200m up a seriously steep hill (amazing views!). The room had 2 beds, mosquito nets, a ceiling fan and an ensuite with toilet and shower. Our board was about 5000 rp/day including all meals and drinking water.

There were 2 English med students there when we arrived. They were very welcoming and gave us the rundown on how it all worked. Basically the routine for 6 days /week was

0830 - breakfast

0900 - work

1230 - lunch

1330 - work

1600/30 - finish for the day

1930 - dinner

The first night we ventured back down the hill at 7.30 for dinner- Manesh, the cook, served up a good dhal bat and tea. At dinner Dr Suman announced that he was leaving in the morning to go to KTM for a week!!! Okay... a short meeting! Not to worry, we (the 4 volunteers) and Dr Suman then ate and chatted in the warm night air out in the open before heading to bed at 9.30.

Next morning we had breakfast of 'donuts'- sort of like Tibetan bread, boiled eggs and tea. I made my way to the Emergency Department to officially start working and Mary went looking for some students and so it begins .....





Below is a copy/paste of the emails I sent home. It kind of sums it up.



9 April

Hi All,

I am fine, now on day 5 of volunteer stint - day off today.

First day was difficult- very different, incredibly culturally different. Also lots of kids and babies (not my comfort zone at all, in fact I haven't looked after a kid or baby since my training)!!!!! Mainly observing day 1. It's a 15 bed hospital with the " ED (2 beds)" and Treatment Room (2 beds) attached. The nurses and health workers look after both areas.

After the first day of not feeling very useful I decided to just to get in and do things so it has been much better since then. Yesterday was good (for me anyway, as I actually felt that I was making a bit of a difference)- it was really challenging with a patient with bleeding from the gut- very unwell, seriously unwell. New doctor from Kathmandu (Dr Suman's replacement for the week) was working which was good. He was happy to work together and treat the guy. We started to treat him but then had to stop as the patient had no family or means to pay!!!! After a couple of hours (and significant deterioration) some money was found in his pocket so we were allowed to re-start! I did some clinical teaching- taught the nurses how to put in a urinary catheter and we generally monitored him. Some improvement but it then became a more complicated issue again as the money ran out! The police then got involved (called in by the staff) and tracked a relative down who agreed to pay for treatment but they were about 6 hrs away. Treatment restarted....

We finished for the day and I went upstairs to the loo, get called down- they (nurses) let the patient get up to the toilet and he collapsed with another big bleed - they dragged him out onto a stretcher covered in blood/crap (sorry you friends with weak stomach) with no intention of cleaning him up. When i asked about it- "it's something the relatives do". So.... no relatives = NO ONE is responsible! Myself and the med students cleaned him up and found some scrub pants for him to wear. The staff were really shocked that we would do this!!??? This attitude is completely beyond me! It goes against all of the principles of nursing that I have learnt and continue to practice- a very steep learning curve for us volunteers!

I checked in on him last night- some improvement . This morning checked on him- he is worse and completely covered in crap again! No treatment overnight, no monitoring. Again, no one will clean him up- it was a losing battle I'm afraid. It is difficult for us ( me and the students) to cope with the treatment (lack of) that the poor or alone get. I am more accepting i guess (hardened). It is culturally entrenched and we can't change it here without creating enormous animosity with local staff, as well as really big community problems- ie creating an expectation that the hospital will treat them free (it just cant). We have to tread carefully. Have to chip away slowly on the basic tasks. I am glad to have the day off today- a bit of breathing space.

The day before was a different kind of issue with an elderly lady in respiratory failure- my opinion was that her death was imminent yet she was transferred to KTM (ambulance paid by her relatives), she would likely die on the 8 hr trip but she was sent anyway.

Staff wise, apart from the young Dr from KTM replacing Dr Suman, there are 3 main health workers. The health workers are very good- quite experienced and well trained- they have a lot of responsibility, they are all male and between 20 - 24 yrs. They are really proxy doctors. Conversely, the nurses are all female 16- 20 and with the exception of the midwives are quite subservient. The role of the nurse is very different here- I'm not sure if it is a rural thing or a Nepal thing.

Another huge challenge is the cleanliness issue! It's my mission to get things cleaner during the next week. Managed to get 1 bit of equipment done yesterday! And 1 of the nurses helped (voluntarily!).

The Nepalis here are very nice, friendly, etc. As patients they are incredibly stoic and patient. In the ward they are all mixed in together; young, old, male, female. There is no privacy at all. All drugs, dressings, everything had to be paid for and collected by the relative before treatment starts.

All in all, it has been a very good experience. It has rekindled my interest in emergency.

Mary was at the school yesterday afternoon for music practice- recorder!!!!! She is doing some English this afternoon. Lots of kids have found out that she is here and seek her out- she is very patient, and really enjoying it. I start after breakfast ( a donut thing, boiled egg and tea). Lunch is 1230- dal baht, tea, then finish around 4. Dinner is dal baht at 730 ish. We eat in a hut or outside the hut next to the goats ( we had a goat delivery yesterday- 2 kids!!!) The 2 english med students here are v nice, there's another Brit Dr arriving Friday. It's a fantastic experience for the med students- they do morning and afternoon clinics with either a health worker or Dr Suman, they can learn a lot, it really hones their diagnostic skills .

We did my Sunday walk yesterday afternoon, out into the more rural countryside, although its hard to see how we can get too much more rural. We were stopped frequently to say hello, invited in to many homes, etc. 4 sisters kidnapped us at one stage and painted tika on our foreheads. It was a great walk- one of the best for the year!

Went to the market this morning - 3 km walk through fields of corn and goats/cows/pigs. Lots of people from even more remote areas. We virtually stopped the market- we were a very curious sight. They don't get too many foreign people here. Mostly selling fabric, beauty products!, veges, tobacco and grains. The meat section sold newly slaughtered pigs and buffalo, lots of flies but not really smelly (very fresh). Came back via the Momo (Nepali steamed dumpling) shop in the town that also sells chai, sweets (sweet, sickly Indian variety- I love them!) and savoury stuff. We had 2 chais, 2 dishes of curried potato and pea soup stuff , Mary had a samosa and pakora and I had a sweet round thing in syrup- cost 70 rupee!!! Less than $1. Consequently I am skipping lunch today- no dal baht! (till dinner anyway).

Weather is hot, maybe 30 degrees. Very dry. Very dusty. My feet are permanently dirty. The cold showers are refreshing! We are relishing having a shower again after the treks. Amazing sunsets- all the dust is trapped leading to brilliant orange skies every night. We overlook the village, valley and hills so night time is interesting too with all the lights twinkling and the occasional forest fire burning.




14 April

Hi!!

So, since my last epic message a week ago what has happened ? Well, my bleeding from the gut patient died. Very traumatic for the 2 med students- sad, but I guess I am more used to death. Death is more common here with a lack of resources and a population with generally poorer health. Having said that, I think this particular patient had a better chance than most here of making it.

Anyway, that aside, the rest of the week passed by very quickly. Got involved in lots of patient assessment and treatment. The scope of injury is pretty wide- motor bike, tractor and other vehicle type injuries, falls down ravines, falls out of trees, lacerations from cutting crops, etc, etc. Also a lot of respiratory illness, high blood pressure and gastric ulcer disease. Primary presenting complaint in the babies and kids was either chest infection or dehydration from diarrhea. In amongst the patient care I managed to get the ED treatment room cleaned out, the nurses got involved too which was positive. Spent a day at the private clinic around the corner and did some teaching with the nurse and health worker there. I thought it would be good for the hospital nurses to have a break from having me around.

On returning to the hospital got stuck into cleaning the ward area. The cleaners are running the other way when they see me coming now! This next bit is really gross- you may not want to read on- but, here goes .... there were 2 bedpans under beds in the ward - 1 completely covered in dust, the other had been used - who knows how long ago - months I'd say AND had half a carrot in it!!!!!! I asked about 4 different staff to get them removed and cleaned- 3 days later it finally happened! I was rejoicing at this! The used vomit bowl only took 2 days of asking to get it removed! The different standard of hygiene is very apparent. Anyhow, I then managed to get the hand towel changed AND the plastic sheets on the ED stretchers changed - a big day!

The staff have all been very friendly and are open to teaching. I feel as though I have learnt a lot from them too. The health workers do a really good job, they take on a huge responsibility for such young guys.

Socially, Mary and I and the med students, Rachel and Mike, have been getting on really well. They are good fun and good hearted- we go for chai tea every afternoon to dissect our respective days. We eat 3 meals a day together and cross over in the hospital so they are like our new best friends. Alas, Mike left on Friday to go to Pokhara before returning to the UK. A new one, Sara, arrived Thurs, so now it's the 4 of us girls hanging out together. Sara is a 2nd year doctor - valuable asset here and is also working on a screening project for Rheumatic Heart disease screening. She is of Sri Lankan origin and has travelled a fair bit. Rachel is a big walker- lots of walking in the uk as well as Europe and Morrocco. We talk a lot about travel as you can imagine.

Mary continues to exert a pied piper effect, attracting every kid within a 5 km radius - she is enjoying talking to them all and helping them to practice their English. She and Rachel conduct recorder classes daily at 3pm. I went one afternoon to watch- one afternoon was enough for me- the recorder is not my cup of tea! The kids here love us (even me), you pull out the camera and they appear within seconds- they love having their photos taken and looking at them- consequently the number of photos we have had now risen to about 8500.

Dr Suman returned from KTM on Thursday - the standard of food has gone up somewhat since his return- chicken curry and papadams with the db one night - and coke!!! Db is still on the menu for every single lunch and most dinners.

Dr Suman is very dynamic, he is multitalented- he is a politician and a doctor, he heads up the clean water program and the installation of toilets program, but wait.... There's more.... He also composes poetry and gives readings! I think he is in his element having 4 foreign females around.

The last 2 days have been holidays here although i have worked for quite a few hours both days. Dr S arrived into ED on Friday with a new piece of equipment - a syringe pump for giving small amounts of potent drugs or infusing fluid at a precise rate to babies or kids. It was donated by the Rotary Club Germans and has been sitting in his cupboard. It also came with the correct syringes..... but no infusion giving sets! My brief was to set it up and teach the staff how to use it. I dutifully got stuck into the task minus the giving sets- I have found a supplier for them so hopefully the teaching won't be in vain. I managed to impress myself with my technical ability in actually successfully removing battery covers, charging up battery packs and getting it all working. Amazing!

One of the other tasks was cleaning out the operating theatre of used syringes and drug vials/ iv bottles and general crap. It hadn't been touched since the last surgical camp happened there. ???When that was?

Today I spent several hours writing a report with my recommendations- I think it provides an accurate summary of what can be improved upon without being overly negative and critical because they do do a really great job with what they have. I think the changes I have recommended are realistic in the context of this type of rural facility. I hope they find it beneficial- much of it relates to basic practices that are easily achievable and will benefit the patient community.

Today was New Year's Day 2070. There was a staff party scheduled for this afternoon. The plan was for staff to prepare some Nepali dishes and the volunteers (us) would come up with a couple of dishes. Rachel and Sara decided on chips (fries) - very UK, and Mary and I decided on crepes filled with bananas and chocolate - very Australian! Well that's what we told them! After lunch Mary and I went shopping for ingredients- we had found a dairy (!!!!!!!!) during the week so had access to milk. We also bought yoghurt that we sweetened (a lot- Nepalis like sweet stuff) to add to dessert if the crepes were a complete failure. Got 5 eggs at 10 cents each, 15 bananas (which we split in half) at 6c each and 15 little dairy milk chocolate bars (also split in half) at 12c each. The hospital had flour, and oil for the pan so we made 30 perfect crepes filled with banana and oozing melted chocolate at a budget price. We have become legendary here, not on the back of our contribution to the health and education of the Manthali population, but as a result of our dessert making prowess!!! It was a really fun afternoon slaving away over a hot frying pan (literally- it was really bloody hot today). No, seriously, it was a great afternoon with everyone cooking together in the kitchen. We all sat down to an early dinner around 5 pm sitting in an open air pavilion at the top of the hill. Our rooms are also at the top of the hill so we managed to quickly change out of our sweaty tshirts before dinner and into our new 'Kurta' dress things- I think we looked stunning in a sweaty kind of way... Pictures to follow. It was a good night- nice meal, Dr S gave a nice speech and it was all over by 6:30!!

Also managed a Saturday and a Sunday morning walk this weekend- mainly to walk off the daily sweet chai tea and the sugary little sweet things they sell at the tea shop. I think my Year of Sunday Walks must be coming to an end.... Maybe 2 years of Sunday Walks???

Last day tomorrow- it has gone really fast! Great experience! I am so glad to have done it. We are leaving Tuesday morning for KTM. Have 2 nights at Tings in Thamel before the Langtang trek. One interesting thing that has come up is an invitation to the Australian Embassy on Wednesday! They are presenting the hospital with a blood electrolyte analyser and a couple of other things so Dr s asked if we'd like to be involved in the ceremony- very cool!

Ok, that's all for now- it's 11 pm- it takes a long time to type a newsy message on the iPhone ( which incidentally met with a nasty accident this week- phone v rock - penetrating screen injury!).




Hope that sort of gives the gist of the experience. I am keen to do some more of this work. There is certainly a lot of opportunity out there. One thing I missed out on was going on some of the rural outreach camps- they weren't scheduled while we were there but Rachel and Sara both said they were fantastic.

To finish, once again, lots of photos....

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Photos

Inner courtyard
Hospital and outpatients on the RHS, Xray room on the LHS

Hospital
The ED is on the RHS, OPD to the LHS, pharmacy, birthing and dental areas in the middle

Operating Theatres
Upstairs level

Post op ward
The ward was only used when the surgical camps were done in the hospital. They did a lot of hysterectomy for uterine prolapse, cataracts, etc

ED
Watching one of the health workers doing a burns dressing