Lots of babies

Yesterday I spent the majority of the day at the Maternity Hospital here in Kathmandu.  As I mentioned in my previous entry, the Maternity Hospital does approximately 19,000 deliveries a year.  This has apparently significantly increased in the last year or two, and the number is continuing to grow.  After speaking to some of the other medical officers / residents, I learned that women who come to this hospital not only can get their deliveries paid for, but also are eligible for free care for any gynecologic or obstetric issues they may have (for example, a free hysterectomy).  Afterwards, in addition to having received this free care (including all meals, which is apparently very unusual for Nepali hospitals), they get 1000 rupees (the equivalent of about 15 dollars US) for transport.  Considering that a 30 minute taxi ride usually only comes to about 200 or 300 rupees for gullible overpaying tourists, for locals, this is a pretty good amount of cash.  As a result of this government offer, women come to the hospital from all over Nepal for care.  The hospital does also have some more private facilities for patients who are able to pay, and most of the outpatient services do have small fees.  However, because this is the only area hospital that runs this government sponsored program, they are struggling to keep up with the increasing demand, in terms of space, personnel and other resources.  (Interestingly, I was told that only a few months after starting this program, the government is already running low on funding to cover it, therefore much of the money now comes from foreign interest groups, including a large portion from South Korea).  

Just try to visualize what hospitals would look like at home if we told people not only would they have no bill, but would be given a stack of cash at the end of the day - as you can imagine, the birth center is quite a site to behold.  There are three main areas that comprise the obstetric ward.  There is one large room with about 30 beds, for all of the pregnant ladies who first arrive, where they are triaged.  If it looks like they might be in active labor, they are sent to another room with about 20 beds, where they sit with a loved one, and wait until they are ready to push.  No such thing as an epidural here - there is no pain medication, and in terms of monitoring labor, the typical patient can expect only an occasional auscultation of fetal heart tones with a stethoscope by one of the medical officers rushing through, and periodic checks from the nursing staff.  Because of the many patients, all of whom are in active labor and therefore making all kinds of noises, the few nurses are not always able to tell which ones are progressing quickly, and which ones just don't cope as well with contraction pains.  Therefore it is not unusual for them to walk past a patient only to notice she is midway through delivering, at which point there is a flurry of activity to try to grab gloves and a clean blanket for the little one that is literally falling onto the bed.  This happened twice in the 20 minutes I spent in this part of the unit.

Once a patient is fully dilated (assuming she didn't surprise the staff with a quick delivery), she is whisked down a hallway to another set of three adjoining rooms, each with 3 or 4 beds - there is no privacy here, no curtains or dividers, and so patients are often going through this experience together as a small group, or one who just delivered will look on with sympathy to her still-pushing neighbor.  Most of the deliveries are done by a cluster of nurses, who go from patient to patient, taking turns with who does the delivery, who takes and cleans off the baby, and which few stand by to loudly cheer on the patient.  There are usually a couple doctors on hand to help with more complicated deliveries, if needed, or to do the occasional uncomplicated one, when things get particularly busy.  Following delivery, if the patient does well, she is sent home about 4-5 hours after giving birth.  In less than an hour, I saw around 10 deliveries done in this way.  

I also had the opportunity to see their crowded antepartum wards, gynecologic wards, and operating theater.  (Again, with the ubiquitious communal shoes - if and when I return to Nepal, I'm definitely bringing my own supply of crocs).  

Meeting some of the new doctors who work here, I got a little more insight into the medical training process in Nepal.  After high school, if a student decides they want to go into medicine, they will go to college to receive a "bachelors of medical science", during which they do all of their pre-med courses as well as the courses that we would consider part of the first two years of medical school, when the bulk of our lectures on anatomy, physiology, microbiology, etc., are given.  They then apply for an internship, which seems to be about a year to a year and a half's worth of clinical rotations, similar to our third and fourth year rotations in medical school.  After this time, they take exams, similar to our USMLEs.  Upon graduation, they can then apply for a position as a medical officer.  At this level, they can write prescriptions, do basic procedures, and take care of patients on the wards, sort of like our interns or first year residents.  At this point, they have usually not yet chosen an area of medicine to focus on, but can do hospital practice in internal medicine, emergency medicine, pediatrics, obstetrics or surgery, under the general supervision of a specialty trained physician.  After a couple years as a medical officer, they then apply for a post-graduate posting, similar to our residency programs, in their field of choice.  Ob/gyn is a three year program here, compared to four years in the States.  

At the Maternity hospital, the wards and the birth center are covered by a handful of interns and medical officers, with a doctor on call who has completed their ob/gyn post-graduate training.  They don't actually have a post-graduate, or residency training, program at this hospital, as it is a government site and not affiliated directly with any university.  I think this is a shame, because this would be a gold-mine of opportunities for a young doctor, and hope that at some point in the future they will be able to establish a formal program here.

It is a pretty incredible facility, and despite the staff being overworked and tired, they all had smiles on their faces, and in between catching babies were eager to share their knowledge with this wide-eyed foreigner.   After witnessing this incredible group for only a few hours, I feel I can now attest with certainty that any medical provider who spends more than a couple months at this hospital would be more than capable of walking into any delivery situation, and handling it with a calm reserve and great expertise.  

So for those who have been putting up with my ramblings about Nepali obstetrics, here are some non-medical observations.  Chris may have written previously about the craziness of traffic in Kathmandu.  Imagine hundreds of New York City cab drivers, tackling streets that are more maze-like and irregular in their intersections and alleyways, half paved and covered in dust and potholes.  Then add to that two or three times as many motorcycles as cars, with all of the vehicles in various states of disrepair.  Then imagine that you took away all of the traffic rules - no stop signs or traffic lights, no speed limits, and even the center dividing line is only more of a suggestion, rather than a rule.  Add to this hundreds of roving pedestrians and feral dogs, and a handful of cows and goats, all trying to cross the roads at random.  This will give you a sense of the insanity of the streets in Kathmandu.  

Now, usually, to get a meal, or do a little shopping, we are able to walk, precariously, on the edges of the narrow streets of Thamel, protected by the other throngs of tourists who are also wandering by.  To get to the hospitals or more distant sites, however, it is necessary to take a car (or for intermediate distances, you could compromise and take a rickshaw, which we have yet to do, but want to try at least once before we go).  So yesterday morning, when I arrived at Kathmandu Medical College and was told that one of the medical officers would be taking me over to the Maternity Hospital, it was my assumption that they meant she would serve as my guide as we took a taxi, to make sure that I didn't get lost.  Most taxi drivers speak very little English, so if I need to go to my hotel in Thamel, it is no big deal as they all recognize the names for the popular tourist sites, most of which are within a couple blocks, but to explain how to get to another non-tourist area in the capital is totally beyond our limited communication.  

So as you can now imagine, I was pretty nervous when I learned that instead of hailing a cab, we would be taking her Honda motorbike (kind of a cross between a scooter and motorcycle).  With my other options pretty limited, I hopped on the back, grabbed on tight, and kept my fingers crossed.  After a few initial harrowing minutes, I was actually pleasantly surprised to discover that it was kind of fun to wind our way through the streets, with a cool breeze in our face.  There is a sort of unspoken courtesy of the streets, that, while not apparent as a passenger in the back of a taxi, you discover with the more intimate experience of being in the open on a motorcycle.  While the Nepalis seem to have no order to their traffic, they do expect all travelers to have a respect for others on the road, and honking here is done as more a sort of warning - a "hey, I'm over here, so be careful not to turn too suddenly" - as opposed to the anger and road rage at home.  Nepalis tend to react intensely (and sometimes violently), if any drivers should be irresponsible enough to actually get into an accident, or, god-forbid, hurt someone with careless driving.  What I had previously perceived as lucky near-misses seems in fact to have been a graceful style of carefully navigating roads that were never designed for this many vehicles.  Not that I am eager to tackle the streets again, nor would I even consider ever actually driving one of those things, but after arriving safe and sound at the hospital, I was glad to have gotten this unique experience, to learn and appreciate a little more about this unusual culture.   

On the surface, Kathmandu is seething with activity, crowded, dirty, loud, and generally scary for a Westerner who is unfamiliar with it's ways, but spending more time here, you discover there is a great deal of friendliness, respect and beauty that goes into all of that craziness.