(2200 Sunday, April 11, 2010)
I just want to put it out there that attendance at morning yoga is dwindling…for the last 2 mornings it has been only Jason and myself… Write your favorite team member an email or a text and call them out – get them to come to yoga! Or at least find out for me if it’s the instruction that is the problem…Jason and I have no formal training.
Today was a full day!! After breakfast (Pete back on track at this point, btw) we headed to Tribhuvan University Teaching Hospital to meet Dr. Ramesh and have a tour of the ED and the rest of the hospital for the team. The University is very large and impressive, and it certainly seems as though there is ample space for all the departments and educational areas. The main hospital entrance is packed with people, coming in to register to be seen in the outpatient department. Their chief complaint will determine which specialty OPD office they are assigned to, and then they move to that area and stand around until their number is called. At any time in the morning or afternoon, there are about 300 people milling about in the hospital’s main floor lobby and hallways. Often they are sitting on the floor, eating, or sitting on benches, or chasing their child around the area. Always they are talking and crowding to be the closest to the door of their designated opd office. Often they push into the office and stand in a line directly behind the patient being seen. No such thing as HIPAA here in Kathmandu!
The emergency room is exactly that – a room. Not the largest room I’ve seen, but not the smallest, either. It seems smaller, because there are literally patients and family members everywhere, on the gurneys, in chairs, on the floor. There is no triage system, so the patients, after being let in the locked iron gate by an armed guard with absolutely no medical or triage training whatsoever. But he looks intimidating; anyway, it gets the job done. J After being let in the department, the patient or whoever brought them in will come right up to the small rounded desk in the corner, behind which the physicians and nurses stand and do their paperwork, call consultants, and generally escape the chaos of the room. There is not much escape, however, as the patient will stand directly in front of them and wave their intake form, stating their complaint over and over and asking every doctor to see them immediately. The physicians and nurses go through the patients one at a time, and often it is the loudest and most vocal patient that is seen first, rather than the sickest. This is the main difference I noticed between TUTH and our system in the US – our triage system allows us to identify the sickest patients immediately, and target them to go back to a room right away and be evaluated. The staff at the triage area also learns the chief complaint and a brief history of the illness, and is able to begin some investigation or treatment, even prior to the patient seeing the doctor. The triage area is separate from the treatment area, really separating the doctors from the chaos of the waiting area, and keeping a feeling of calm in the department, leading to improved physician performance and patient experience. The nurses at triage, of course, are subjected to the stressful environment for long periods at a time, and because of this they change assignments every 4 hours.
Unfortunately, we are unable to work in the ED at Tribhuvan, as Ramesh has made inquiries of the Department chair and he has not yet received permission to make an invitation to us. Politics, politics. We plan to make those arrangements for the future fellow and next team. Dr. Ramesh took us on rounds, however, and explained each patient’s complaint, exam, work-up and treatment plan, consulting us frequently on complicated cases. They have “boarding” in their ER the same as we do – it seems that their inpatient departments often operate at >100% as CCHS does, illustrating again that there are many similarities in global medicine, despite all the differences.
We spent a little time with Dr. Ramesh in his office, where he sees patients in a study having to do with tropical fever, in collaboration with a group from Thailand. We then had a lovely meeting with the Director of the Tribhuvan Nursing School, who was asking whether or not we have a nursing school in DE that would be interested in an elective exchange program for nursing students. They have RN students from the UK, Sweden, Netherlands, Norway, and Germany who come for 4-6 weeks for a clinical elective here at TUTH, as well as in various rural community health centers. I think this will warrant a conversation with the U of D nursing school director. Oh, the conversations I will have when I get home! I certainly think that this would be a great place for a nursing student to broaden their scope of practice and sharpen their physical exam skills, given the lack of resources.
We had a brief lunch, and then the residents went with Dr. Ramesh for his bedside teaching session with the senior medical students. This is a great way to observe the teaching process here, really see the knowledge level of the medical students, and hone their own teaching skills in the process. The case was a middle-aged female with no urine output for seven hours, likely urinary outlet obstruction. The students presented the case and discussed the differential diagnosis. The woman who was the presenter seemed to struggle a bit, but in general they seemed bright and enthusiastic, eager to learn and discuss the medicine.
Once we were all back “home”, we regrouped and decided to go with Bikki to his orphanage to meet the girls. Bikki and his father run an “orphanage” for 10 girls from the ages of 4-11, which is partially funded by a national organization for homeless girls, and the rest by Bikki and his father themselves. I put the word orphanage in quotations, because unlike what I think of as an orphanage, where parent-less children live and are taken care of while waiting to be adopted, a facility of the same designation here or in India appears to be almost a family, where the children are not adopted by the family, per se, but they are not at all up for adoption by anyone else. The understanding is that they will live at the home until the age of 18, when they finish secondary school. They will be prepared to enter university at that time if they choose to do so. Some of them are orphans in the truest sense of the word, but many of them are daughters of single mothers, who could not afford to raise them on their own, and decided to give them up to the orphanage. The parents have relinquished all legal rights to the children in those cases, although they sometimes get to see their girls for a day or two surrounding some holidays, if they choose to.
Bikki’s girls are ADORABLE, simply a breath of fresh air. All of their little dark heads of shining hair bobbing around the playroom, as they trade dolls, play games, and hop over one another in games of leapfrog. They all gathered around a game on the floor, which looked like a combination of checkers, backgammon and air hockey – apparently you have to flick the various checker-like pieces into the corner pockets. One of the girls was incredibly gifted at this game, and could probably have won enough rupees from the audience to buy an entrance fee to secondary school!
We went outside to the rooftop with the girls, where they often play Frisbee, ball, hackey-sack (they’re WAY good at hacking, as well!), and dancing. I just MUST share some photos of these adorable little cherubs! They sang in unison while each one came forward individually and danced a traditional Nepali dance, with arms and hands curling in front of them, feet carefully stepping left and right to the beat, and spins that would make anyone dizzy. They seemed to be having a ball performing for us, and it was easy to tell which ones were the next ballerinas or Bollywood dancers. (Or whatever dancers they have in Nepal besides the ones on the signs in the streets of Thamel that come out at around 10pm as the boom-boom-boom-boom music starts.
We had brought our medical bags, and so we gave each of the girls, as well as their housemothers, a full check up. Most of the girls were perfectly healthy, as Bikkis had assured they would be, but the housemothers had a few issues, so we make some recommendations. One little girl appeared to be recovering from a viral illness with enlarged lymph nodes, a fever, and a headache. We removed the makeshift bandage that someone had placed there 5 days prior. She apparently was improving greatly – no further fever, pain almost gone, eating and drinking well. We planned to return on Thursday for a re-evaluation, to ensure that she is continuing to improve.
We were reluctant to part with the lovely angels, but it was quite late. We handed out some gifts we had brought them – just some puzzles and learning games – which they seemed to like very much. It’s always a great day as a parent when one of your so-called friends introduced your child to blue Play-Dough… Blue carpet, here we come!
Bedtime was early tonight, as the girls wiped us out. Looking forward to tomorrow, when apparently there is going to be a Maoist Strike about the price of passports and needing passports to go to India from Nepal. All of the city of Kathmandu inside Ring Road is apparently going to be shut down, and therefore there will not be any card on the road, no taxis no nothing. Work at the hospital will be impossible, unfortunately. But I am sure we can find something fabulous to do.
Thank you all for your wonderful email replies and support. We are having a wonderful time, but obviously we miss you and or homes. I apologize that this blog is about 3-4 days behind schedule, but we are just so busy, I have to schedule time just to sit down and write!
More soon, Namaste!
Sue/Team
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