An overdue (and very long) medical update

Time for another post from Melissa (and again, very timely, considering that Chris' blog from today is just a random smattering of highlights from the Kathmandu Post).  

So it's now been a full week that I've been "working" (more like shadowing) at Kathmandu Medical Center, and I've seen quite a bit.  Please forgive this very long entry, but it's been an eye-opening experience, and this only just brushes the surface of all I've seen.... 

After my introductory tour of the hospital, my first full day was pretty much spent chatting with Reena (the one and only ob/gyn resident at the whole hospital), comparing how we do things on opposite sides of the world, and finding that, at least in conversation, most things are quite similar.  A laid back day.

The next day, Reena was supposed to be in "OPD", or clinic.  This turned out to be quite unlike clinic back at home, where every minute of my time is tightly scheduled, and spent running from patient to patient, apologizing profusely for being late, and then spending even more time trying to catch up on writing notes.  Not the case here.  Clinic started at 9am.  We managed to get there around 10:30, after some delayed rounding and reviewing the few hastily scrawled words that sum up an entire day's worth of medical care.  Their clinic is basically a hallway, divided into rooms by curtains strung along every 8-10 feet or so, with each cubicle containing a desk and few chairs, and an examining table with another curtain.  So patients who are to be seen in the last cubicle walk through the others where patients are being interviewed and examined, and occasionally pause to listen in as we discussed details that most people would blush to hear (this in an ob/gyn office, after all).  No such thing as HIPPA here (the at-times militant set of rules that governs privacy of personal medical information in the US).  About an hour into the experience, we were seeing two young women who came in together, one concerned about maybe having an STI, and the other wanting Norplant (which we don't use in the US anymore, so it was pretty cool to see it  actually be inserted, rather than just reading about it in the "items of historical interest" section of our textbooks).  

At around 1pm, we got a call from Dr. Chanda, who is the doc that is organizing my time here.  She asked if we wanted to accompany her to another hospital in the area where she was headed to do a C-section.  So just like that, despite a waiting room full of patients, Reena and I were in a cab, headed across town to the private hospital.  I learned that this hospital was different because patients were expected to pay "a lot" for the privilege of staying in an open room with only 6 beds or so, as opposed to a free stay at the teaching hospital in a room with 20 beds.  Now patients at all of these facilities might get a bill that includes the cost of any procedure that might be performed, or for their bed, particularly at the private hospital, or if they want a bed in a somewhat less crowded room.  However, they are expected to purchase and bring with them any disposable supplies and medicines that might be required during their stay - so they routinely show up with a bag that includes a couple pairs of sterile gloves, bandages, antibiotics and pain medications, and any other supplies that in the US, we usually keep in bulk at every nursing station.

The cesarean section at the private hospital was my first experience of the operating room in Nepal.  There is a room where you take off your shoes, and put on a generic pair of crocs that are only to be worn in and around the operating theater (crocs that many other feet have worn before you, and which you probably don't want to know when were last cleaned... I still haven't figured out, after a week, why they are so fastidious about changing into these OR shoes when little else about the process seems particularly sterile...).  We then changed into scrubs, and move on to the cluster of operating rooms.  There is little used here that is disposable.  All of the drapes are of a thick cotton material, even most of the sponges are rewashed and reused.  Not much gets thrown away at the end of the case except for the gloves, which again, the patient bought and brought with her for use in her surgery.  What probably shocked me the most, was that not only are they doing c-sections in sandal-like versions of crocs (visualize the open-toed "shower shoes" of college days), but they actually took off their shoes and operated barefoot in a procedure that at home, we wear knee-high waterproof boots for (c-sections are probably the messiest of all surgeries).  While I was somewhat frustrated to be restricted to the sidelines to just observe, I was grateful to not be in the splash zone.  

The next day (and after a thorough foot scrubbing after getting back to the hotel), Reena and I were invited to accompany Dr. Chanda to one of the ritzier hotels in Kathmandu for a conference.  Dr. Chanda is one of Nepal's leading doctors in reproductive choice, and was one of the first to start performing terminations when it became legal here a little over 5 years ago.  This conference was set up so that a group of researchers and public health leaders could present the findings from their just completed study about complication rates associated with surgical first trimester abortions.  This is the first study of its kind in Nepal, and the next day there was an article on the front page of the paper about the study, and how well health care providers are doing in terms of making change.  Complications associated with abortion care are a major component of maternal mortality in places where women are forced to go to illicit providers, who are usually not trained in medical or surgical care - this is why making and keeping abortion legal, while at the same time expanding knowledge about and access to better contraceptive methods, is so vital, and saves so many lives.  The conference was a great opportunity to meet some of the women who have helped to make this huge change in Nepal.  I was also pleased to learn that, unlike the situation in the US, where many clinics are surrounded by protesters, and providers are often threatened or worse (like the recent murder of the doc in Kansas), here in Nepal, once the laws were changed, the public, in general, seems to have accepted legalized abortion, and signs for clinics are posted publicly where they can be recognized and therefore the services utilized openly.  Pretty progressive (or, more likely, the people are just too focused on bigger issues like getting safe drinking water, stopping the cholera outbreak, etc).  

The next day, we were back in the operating rooms at Kathmandu Medical Center for a full day of surgery.  While technically the procedures are the same, the differences in the culture of the operating room were pretty profound.  Our OR staff runs a pretty tight ship - schedules which are constantly updated, and detailed computerized systems.  Patient monitoring with name bands and checks at every corner to be sure we know who is where, and that we are doing the right thing to them.  The scrub nurses are like hawks, always keeping an eye on their sterile field, and if you should even approach the margins of that sacred zone, watch out - you will get a stern lecture, and if you should actually violate the sanctity, and (gasp!) contaminate the field, you are in big trouble!  Not at all the case here.  There is a single unmanned desk, with a pile of roster books which the medical students will periodically write down the name and procedure of whoever they just watched have surgery done.  Above this desk are a few printed sheets that list a tentative schedule of the days cases.  This schedule is by no means adhered to.  We changed the order of every single case (including, for reasons I have yet to comprehend, moving the potentially fatal possible ectopic to the end of the day - fortunately she did not have an ectopic, was possibly not even pregnant, as she just had a small ovarian cyst, and a several day old urine pregnancy test result from an outside clinic).  Most of the time, our anesthesiologist and nurses had no idea which case we were doing until we walked the patient into the room, and this was routinely done while the dirty stuff from the last case (I'll spare you details...) was still in the room.  And of course the patients were walking in - you guessed it - barefoot.  In one of the more shocking moments, while under anesthesia and in stirrups, a patient's foot dropped onto the sterile field not just once, but twice.  No one even batted an eye - they just put the patient's leg back into the stirrup, with a single velcro strap, and continued on, using the same instruments from that same table.  

Alright, so I'm probably going a little overboard with the shock value here.  The doctors here seem very good, and I think they are doing the best they can with the limited resources they have available to them.  They are aware of the deficits in sterility, and attempt to make up for them by putting all of their patients on 24 hours of heavy duty antibiotics.  Maybe not way I would attempt a solution, but better than nothing.  I also had the privilege of watching one of the only two female gynecologists in Nepal who is trained in laparoscopy.  Now, coming from an American hospital where we learn from faculty who are national experts in laparoscopic technique, this was far from the mastery of the skill that I've come to expect from my teachers, but still, just the fact that she was one of the first in her country to even attempt to adopt a minimally invasive approach was pretty impressive.  

After an eventful week, I had the day off yesterday to spend with Chris (and our new friend Bruce) exploring the temples and museum in Patan, as I'm sure our avid blog-readers are aware.

Today was back to work, with another morning spent in the OR, followed by spending a couple hours this afternoon at one of the Nepal's largest Comprehensive Abortion Care clinics, where I could see all that I'd heard about at the conference in action.  Again, the sharp differences in both patient privacy and cleanliness were a bit shocking (although I did get to wear another lovely pair of communal crocs).  However, it was great to see that these women at least have a safer option - particularly after my earlier experience in the OR, where I was witness to the result of what a botched procedure looks like when a patient came in after three, that's right three, attempted procedures in a little rural town with no trained medical provider.  It was very scary, and she is lucky to have survived.  

The rest of my week will hopefully include more obstetric experiences - I still have yet to catch a normal delivery, as well as perhaps a tour of another nearby hospital.  Dr. Chanda has offered to take me around the Maternity Hospital.  This is a huge facility, run by the government, which only does obstetric and gynecologic care, with a small pediatric wing for the newborns.  They do 19,000 deliveries there every year!!  Over 50 cesarean sections a day!!  I've been told, that spending a few months in this hospital would teach me everything I ever wanted to know and more about the practice of obstetrics and bringing new life into this world.  Unfortunately, I'll probably only get a couple hours.  But I'm still looking forward to it.  Another interesting note about this hospital - apparently the government will pay for a woman to have her delivery here, which is why they get such a huge volume.  Every women can have up to two deliveries on the government's dime, although since they don't really keep any formal medical records, that means that any woman who shows up, no matter how many kids she has, will get free care.

Ok, that is more than enough for now (Chris is reading over my shoulder, and telling me this entry is way too long--"enough doctor talk").  Hopefully this hasn't been too boring for all those non-medical folks, if any of you have made it with me to the end.

I'm having an awesome time here, and hopefully will continue to have some great experiences in our last week in Nepal, before we head back to a place where it's safe to use the tap water when we brush our teeth, and where I can wear my own shoes to operate in.