Friday, February 27, 2009

Greetings from Nepal!!

I know it has been awhile (ok so only two weeks--but time feels differently here) but I hope you have not forgotten me and my Nepal stories--because here come more to jostle your mind! (read: its a long one---again grab a beer, panni (water), coffee, chiya (tea) and be prepared!) I was in a little town called Ghorahi in the county of Dang which is western Nepal. :)

I am back in Kathmandu--after a crazy 19 hour trip was only supposed to take 12 hours--but there was a road strike (of course--just my luck) so we had to go the extra 6 hours around to get to Kathmandu. I got in around midnight---slightly freaked out if I was going to be able to grab a taxi and get me to the hotel. Plus i had no idea if the hotel was expecting me. So I befriended the only slightly english speaking Nepali and won him over---he lent me his cell phone to call the hotel---they were lights on and waiting for me once I got home! (wow i just called it home here in kathmandu---pretty crazy)

My experience in Dang was absolutely crazy. I lived in the hospital which added to the craziness---the Dog gang outside of the hotel was worse than in Kathmandu--one night I finally got a peak and saw the dogs running happily down the street while happily barking away --free from passing tractors, cars, motorbikes, bikes, cows, goats, etc etc etc. It is definitely their turf at night. :)

I ate dhal bhat and sag every day, two times a day. It is rice, and lentil curry and bitter BITTER boiled cabbage. It got old. REAL fast. But what was I to do? It was free and all Nepalis would be grateful to get that much food everyday---so with a happy smile I scarfed it down like it was the best food I'd ever tasted. Every day. Twice a day. for two weeks. you get my drift. BUT the morning coffee was still the best I've ever had---starbucks has something to learn! I have also eaten cooked fish---the whole fish with the eye staring at me---they are lightly fried....its pretty awful actually. the bones are nasty and I spend the rest of the evening worrying I am going to perforate my intestines (yes i am paranoid at times). Sadly my peanut butter jar is finally finished---it has lasted me a month (I"VE BEEN HERE A MONTH!?!?) so it did its part. So that is the update on the food....My mom is getting in this evening (WHOHOO!!!) so I am ready to eat some good stuff with her---some of the curries are amazing so I am hoping to stick to that for a few nights....

The cases. Not much OB. Mainly gyn stuff so that was good. But I also worked a ton in the general clinic and emergency. I saw two cases of Miliary TB----the chest xray was text book---it was so sad though---the prognosis can be bad. Luckily for that DOTS program I was telling you all about (gov't requires ppl to come in daily for the meds) people actually live good lives through TB. I saw many cases of typhoid---high fevers, headaches, and usually constipation although diarrhea can be can be quite serious because they can perforate as well. I saw a lot of PID---pelvic inflammatory disease---but surprisingly it is not usually from sexually transmitted diseases---hygiene is just so poor that B. Facillis is usually the case (although it was never cultured so who knows...)

I debrided a burn wound that took up half a 72 year olds man's thigh---it happened 15 days before he came to the hospital and was VERY infected. He smelled awful---I am pretty sure it was pseudomonas. The burn was from a candle---since he lived in a village and had no power. I had a 7 year old with a type three supracondylar fracture (its basically an elbow fracture for the non medical readers) with vascular compromise---her hand was cold, without a pulse and decreased sensation to her hand. She needed surgery. I tried to reduce was actually a really good reduction but still no pulse---so we sent her to nearest surgical hospital. It was a three hour drive.

I helped with a bad case of COPD and cor pulmonale (right heart failure) of an amazing 60 year old lady---she had pitting edema (swelling) up to her sacrum. All the woman get COPD here---not because of smoking, but because they cook with a wood fire. She was the hospital first charity case. She didn't have money for even food. (the hospital does not provide to the inpatients!) I bought her a pair of shoes---she couldn't afford any and wouldn't walk because her feet were so swollen. I loved her and was sad to see her leave---no money left and was O2 dependent. So she went to her village and will probably die in a couple of weeks.

And I had two TERRIBLE awful sad hearbreaking deaths. They were one day after another of less than one year old baby boys. It was awful. The situation in both cases was just so sad--i dont think i can comment any further right now.

Every day we rounded twice in our 10 bed inpatient hospital-once in the morning, once at night. The labs we were able to do: HIV, malaria, TB, urea, creatine, CBC, ESR, and urine. THAT WAS IT. So for the severely dehydrated patients we had no idea what their electrolytes were. We just just look for renal failure. We had no culture capabilities. So we treated empirically for everything. Luckily resistance for like pneumonia isn't bad, so we could use basic antibiotics--which is good since we didn't have anything else anyway. The only IV pain killer we had was something like pethidine ? I have no idea what it was truthfully, but I dont think it worked so well. Dr. Sanjeev was the only doctor (does it sound familiar Pancho??) so he worked 24 hours 7 days a week. Overnight the paramedics (think of an 8month training after tenth grade---they really knew nothing) would see the patients and then call him if anything happened so he could come in. But there was a brittish doc there as well---Dr. Jessica (no one goes by their last name) and she was just great!! We immediately became great friends and she taught me a lot. She would work with Kumar--one of the paramedics--at night because he had the best english, so that gave Sanjeev a break.

I had to get used to people staring at me. I guess seeing a white girl is pretty rare---I am thinking most people out there have never seen one in person. I had people (random people) ask me if they could take my picture with them. It was so bizarre. I would be just walking to buy some bananas or something, and someone would walk up to me holding a mobile phone and ask to take a picture (in broken English). Better watch out---I am famous now! Hahahaha

I ran a few times in Dang---it was goregous scenery with rolling hills and a river. It was amazing. This really surprised the people---to see a white girl running by. It even surprised them more when I would pant “Namaste!” to each of them or “Good morning” their eyes would jump out of their sockets and then they would smile and yell “Hello!” or “Namaste” back---it was awesome. The security guard was named Shreedhar (Shre-dar) but I called him Shredder--like the Rat from the Ninja Turtles—because I felt like he was my personal protector and I am pretty sure he could do some Ninja moves if necessary (I might have just imagined him doing these…). I loved him--he didn't speak any english so we spoke with my 30 word nepali vocab and lots of hand motions...he was an ex police man so was into running and exercising with me--it was just great.

My main contribution to the hospital was putting together the emergency bag. After their first code (i missed that one--it was a week before I got there) Jessica said it went so poorly that something was to be done. So we bought a computer case type bag and I put it together. It consisted of two ambu bags---one pediatric and one adult (we only had two fask masks---so we cleaned them with spirit which is ethanol drenched cotton---definitely not US standards) and two laryngoscopes--one peds one adult, but we didn't have batteries for the adult and we didn't have pediatric ET tubes (the tube that goes down the trachea to help people breath when we intubate) so we really couldn't intubate anyone....I also put IV cannulas, NG tubes, fluids, and then made a drug box of adrenaline, atropine, dextrose, diazepam, etc (all meds necessary for a code arrest or seizure). I also made saline flushes since those don't exist here. Hopefully it will be a big help the next time a true emergency comes in. Because the way it worked before---we would need to put an IV in a patient, but first the family would need to buy one, so they would go to the pharmacy (which is attached to the hospital) and buy an IV cannula and then come back with it---this could take up to 5 minutes and really delayed the treatment of the emergency. This also goes for medications, fluids, oxygen, etc etc etc. At least some of the real saving stuff is ready available and then the family can just pay to replace it in the bag. Does that make sense???

well that is the best update i can give right now--more after my travels!!

Saturday, February 14, 2009

Subha prabhat!

Oh my dear friends!

There is a gang that takes over at night. At first I was sleeping through the night (mostly) without a problem, but around 2 or 3 in the morning I can hear them strutting their stuff on the streets, letting their presence be known!!! Yes, I am talking about the stray dogs. Howling in the night. at first I loved the stray dogs---I even saved some breakfast to feed one (french toast)...he turned his nose up and walked away from it! That was the last attempt, trust me....Anyway, so I have started using my ear plugs at night to sleep, which means I sleep through the watch alarm...but you all know its no big deal since it is absolutely impossible for me to sleep in. :)

update: i leave for Dang tomorrow! WHOHOO!!!

So back at the hospital I must explain the confusion I've had recently. Apparently to the Hindus the year is 2065. The date today is 28-10-2065! Whatever that means. SO the ladies NEVER know when their last menstural period was...and when they do know, I have no idea what that means since I go by the the 12 month calendar that we all depend on (MATCH DAY IS TOO SOON!!). And I found out that next year they will be deleting their last month because the stars and their calendar are just not matching up...... Imagine that.... Then imagine if you were told that we're just gonna delete December this year.......

Now imagine you are a woman patient to see me and the lovely doctor (I LOVE HER!) enter a small door into a small room that has one white desk and three chairs---the doctor sits in one, I sit in the other, and the patient sits in the third. Then there are about 10 nursing trainees who loom a half circle behind you, listening to any menstraution problems or discharge, while your husband tries to listen outside, or sometimes comes IN and chimes IN! Then three white sheets are strung up behind you were you are told to lay down on a sheeted half bed and put your feet up (no stirrups). Then via flashlight (more on power outtages below) you are examined with the 10 trainee nurses all tryingto get a peak (the sanitary issues for the speculum and such will not be described---they do their best here, but it is NOT up to standard by any means). Then during one of the breaks--we see from 4 patients to 24 patients in a 2 hour span---so some times there are breaks---one of the trainees plops herself down and tells the doc about her anal puritis. I am shocked---there are not many people I would share this little issue with! But she is not embarrassed (my guess was pinworms) and gets the treatment without a blush.

Oh and on the outpatient side---we check anemia by looking under the eyes of the people. If they are pale, we assume anemia and we immediately treat for hookworm since that is the most common cause of anemia here. No tests necessary.

In my attempts to recreate some sort of normal lifestyle, I have found an amazing coffee shop! It is very clean and they have free wifi and american music playing. So I go there when I am absolutely freezing in my room to warm up and studyNepali. I have to say---its coming along alright. I learn a phrase or two a day. But it is very difficult and I finally realized why. When I first got here I was so upset because it seemed like the doctors would talk to the patient for like 5 minutes and then would turn to me and just say "he has fever for 5 days." I would always be like...yes? and what else did you discuss?? but it is possible that was it! For exampl;e to say "you're right" you say "ta-pai Le thik bhah-nu bho-yo." damn. i guess if you're gonna tell someone that they're right---you will better mean it!! Anyway, after they played the Aikon song "I'm so lonely" TWICE---I had to was hitting a bit close to the heart, ya know?

Oh! and don't think America is the only one with Pharm reps! I've had two sightings on my short stay here! They come VERY nicely dressed---you can definitely pick them out---and have little signs on each of the drugs, giving a sales pitch---when you think calcium think pearl-one!

Today I did Tot Shots Nepali!! Tuesday is shot day and we give polio---two drops of a liquid into the kiddos mouth and then one shot of HepB, DTap, and something else. I did well until--like my lidocaine accident when I was numb for a hour when it exploded in my face---I exploded the polio bottle in some unexpecting 2 month kiddo's mouth. He is well protected. :) Also they put eyeliner on these 2 month kiddo's eyes! Its supposed to be ramro--or beautiful. So its so interesting to watch the very nicely eyeliner eyes go from happy staring at me, to sobbing as I inject health into their little plump leg.

I cannot seem to get the power situation correct here. Just when I think I've got it--its all been changed. Right now we get power from noon to four pm. Then power comes back on at midnight to 7am. The gov't realized that giving power during the day is absurd because we use it! So instead they do it at night when we are supposed to all be inside and sleeping anyway. I am not too sure how long they will last. But the good news is---they may or may not be increasing the
power times! we find out next week--all very exciting.

Thursday, February 12, 2009


Hello folks! Well I have officially been out of the country for 2 weeks now! Its pretty crazy....I dont have much time to write a full post, so I will instead put an email down that I sent out from my first week....its been INTENSE, but good....missing everyone!!

Namaste! and subha sandhya! (good evening!)

this is to be the longest email ever! so please...grab a cup of coffee, beer, a glass of panni (water), and then come back to read this!!

Firstly I would like to thank everyone who has written me an email---you know you who you are. They mean a lot---I feel like I am actually having a conversation sometimes. :) and it has been great talking to some of you over phone! So I start this email there---I may sound sad and upset and possibly cry over phone. but please know---i am doing good....really good. I just get a bit sad over the phone because I dont have "normal" conversations here and so it comes out over phone. SO know that I am good--unless i say so, of course---and that I can't wait to hear about you! even if i make the phone call all about me, because to be honest, i dont speak that much around here. :) (EXCEPT FOR MY JOURNAL---court---i write in that at least twice a day!!)

ok about nepal. I am living in Kathmandu---in the Thamel area---a very touristy area very busy, someone is always trying to sell me tiger balm, or a shirt orm out from 8am til about 9pm (tonight is the exception but you will see why below) because there is little power (sometimes none) and so that is that. Today marks my one week experience here and I have to say at the end of th week--i am so glad i have come.

My first 24 hours i desparately missed my cellphone---i longed to make a quick phone call to say hello, chat about whatever, etc etc. I also realized how dependent on my ipod i was---when i didn't have power to charge it and it was completely dead. Luckily i am able to charge it from 6pm -8pm so i can listen to my music before bed (you know how i am). it took a good 48 hours for me to let go of these, now seemingly silly, necessities. i have gotten over that, although finding a place that only charges 5 cents per minute to call, means i can call more frequently (although this has come to an end---keep reading) and proabably have this week. (Thanks to those who have answered!!!)

I'll start with my daily life this week (And please know this comes mostly from my journal): I wake up around 645 or 7am...i wake up to crows or dogs barking usually. or the luggeee (sp?) man who lives somewhere near by---it wasn't long before I became the luggee woman---the dust and pollution help create some good ones!!! SO i get out of bed and begin doing my "workout" this consists of wall sits, push ups, situps, pike ups, etc etc etc. i cannot run here due to smoke, dust, pollution so my work out is inside...without a gym. I then sometimes take a shower (nicola and court--you should be proud---its been 3 days!!!) but the hot water is solar power so really it would be better for me to do it in the afternoon but i just dont. then i will write, read, or pack up my stuff, etc. I head to breakfast usually around 845 even though they ask me to come later everday. I drink milk coffee which costs about 70 cents for a small point--and this is possibly the best coffee i've had in my entire life. in addition i have french toast, or toast (depending on the belly). Ratna, the man who drives me to work everyday, is always punctuional (i am constantly suprised when he is there) and takes me the scariest 25 minute drive to Chabahill---the name of the area of where the helpnig hands hospital is. I have gotten used to the roads, although the first few days were awful. The pot holes are as big as I am, there are people walking every where, motorbikes, other cars, somehow we have not hit anything (knock on wood). I honestly don't know how he does it, but I love him for it.
I arrive usually around 10am but the doc arrives around 1030 or so. I work in the outpatient clinic in the mornings---I have seen typhoid, hepatitis (type unknown--they dont bother figuring it out unless it lasts for a long time), many many many pnas and chronic coughs. Which brings me to the TB situation. The people here pretty much have TB. Young, old, etc it doesn't matter. And the people refused to take the medication---even when it was basically given to them. SO the gov't (more on that below) has instituted DOTS---a system that requires people to come to the hospital everyday---they sit, take their medications under a person's supervision and then they can leave. in return they get something reduced (rent or something). its crazy to see the line of people everyday. to see the outpatient doc--it costs 60 ruppees or about 85 cents. to see the OB/GYn--its a bit more expenisive---150 rupeees or about $1.75. crazy eh? to get a CBC its about a dollar. it is costly to the people, but not just low enough that they will pay. they come from all over teh country---one family took 10 hours trip to get there. the clinic has been open 4 months and they ahve seen already 20thousand patients. pretty good i think.
there is no ICU, but they have an inpatient of about 12 beds. there is one OR and one post op room that holds about 8 beds. I have lunch in a office---i eat dumplings basically everyday. i now HATE dumplings. :) In the afternoon I finally get to do OB/GYN.
I love the OB docs. I also love the OB nurses...well one is a sorta nurse, and the rest are just training. but they are super friendly and have taught me most of the nepali I know (I can now ask if the pt has a fever, a cough, pain anywhere, and for how long...the ob stuff is much more complicated to learn, but i'll get it!). The OB stuff is great---they definitely estimate fetal age based on physical exam---how big the uterus is, etc etc. We listen to the fetal heart tones by stethoscope!! I have never seen this in the US, but it works well. I have also seen so many prolapsed bladders, and many many many cystoceles, rectoceles, etc etc. Menopause is late here---woman start around age 54 or so. So it is common to see a woman on her 7th pregnancy at age 45 and still baring a child. abortion is completely legal here, and surprisingly it has become more of a birth control method than anything else---i bet the prolifers would love to hear that. Woman refuse to use OCPs so they get pregnant, and the docs take care of it. pretty crazy. They dont run many tests here----so if they see discharge---they decide what kind it is (yeast, bacterial, etc) based on appearance and then they treat for it. No wet prep test, etc. today my last patient---had suspected choriocarcinoma. I actually felt her uterus enlarged and another mass. They'll take it out next week.

So after work, i get home and read. I read by head lamp when the power is out. The power goes out random hours. I never know when it will be there or not. But it sucks when it is out and i'm in the middle of something---the joke is my room probably looks like watergate from my head lamp. I fall asleep around 9pm and then I get up and repeat. I have finished two books so far---first one was a bunch of short stories about nepal called royal ghosts (about when the royal prince killed his entire family and then himself---pretty intersting) and a jodi piccoult book. I tried reading about the history of tibet, but the book was SO dry that I sold it. I am now on book two of the twilight series.

so my big news. last night i met with the founder of the helping hands organiztion. i went to a dinner at his friends house. it was a very nice house---even by US standards--of course I couldn't see much of it because the power was out when we first got there, and i felt ridiculous getting my head lamp out, so we pretty much sat in the dark for the first 30 min. then the lights came on at 8pm and I saw we were sitting in a large living room that had four couches. I was on one of them and then there were about 8 nepali men on the rest, and the woman sat on the floor. i almost jumped up then to sit with them. I was given a homemade alcoholic drink--to which i took one or two sips of---(i was so worried about offending people) and then a large bowl of hot water with a lemon in it was brought to me and the founder. i was told to wash my hands. I copied the founder. Then a large plate was brought to me---one side had hard seeds, sausage on another and fried meat on the other. I first tried the seeds but they were so HARD that I couldn't even chew. I left those alone. So I tried the sausage, but it had the weirdest spice that I gave up on that. I was about to try the fried meat when the founder told me it was goat intestine. My stomach flipped. So I said I would try it. Lets just say I did and there was no second bite. then other things were brought---a doughy type thing, a couple of chips sorta things, carrots ( I ate all of those) cold vggies in a strange sauce. and then another fried meat. I was ready to eat it although my stomach WAS NOT HAPPY at this point. they told me it was fried goat lung. a fine nepali delicatesee. SICK. I took one bite and knew I was done for. I tried to figure out where the bathroom was , just in case. This whole process was but 1.5 hours. During this time I was told my trip out east was canceled, and instead I was leaving in 3 or 4 days (no one knew) for the west where I will remain until my mom comes. I was shocked and a bit pissed no one told me before hand. So I started saying that I was Full---no more fried meats for me. And this entire time the people kept speaking Nepali to each other--so to busy myself I acted like JD from scrubs (something I now do regularly) and drift into my own head...this time i pretended they were plotting ways to kill me---i envisioned how i would escape everytime---from posioning to beating me up===I would dodge it all with my trusty 25 spray pepper spray that is always in my pocket. I was finally brought fried potatoes and asked repeatively if iw as on a diet. I was then told this was just the start---the real dinner was to come. My stomach flipped. again. So I ate the potatoes and hope I misunderstood.
I didn't.
the real dinner was bout 30 minutes later---in the dining room---rice, goat meat, curry, lentilss and truthfully it wasn't bad. but my stomach not being happy already could only eat a bit---more jokes about dieting ensued.

SO I leave monday or tuesday for the west. i am promised to have internet and phone booths but i am guessing they are mucn more expensive so I will not be writing or calling as much. I am told I will be the only OB doc...for which I replied that I was not qualified for that. and I am told I may be living in teh hospital...for which I hope is a joke, but guess it is probably not. I am told the Maoists are at peace here (although a year ago it was not the case) I go there with the founder and so if any problems arise, I come back with the founder. I am excited to leave kathmandu---this is a busy polluted city...i would love fresh air!! But I feel very safe here--probably because I go to bed early and dont go looking for trouble, but also---the people here are SO friendly. The nurses==who live on less than a dollar a day---bought me tea today to say goodbye. I was so moved I almost cried.

And if you felt the earth move this morning---i had my first dance party in my room tonight. picture this: me listening to Counting Crows hanging around here and dancing like no-one-could-see-me in my room. I am happy here. BUT I MISS ALL OF YOU!!!