Report from Nepal
Below are the three posts Dr. Segil mailed out while on medical mission in Nepal,
Monday oct 2, 2017
We are at Chitwan Medical college Teaching hospital, Bharatpur, Chitwan, Nepal.
We flew about 25 min north from Kathmandu to get here, only a four hour ride, but the roads are so bad it can some times take all day to get here if at all. This is a Huge teaching hospital, 750 beds (Wentworth Douglas is 150), over 4000 delivers annually, a three year medical school, as well as dental, nursing and a total of 11 paramedical specialties. It is a private hospital. They see approx 1500 Out patients daily in all of their specialty clinics.
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We are a group of 16 mostly US medical people, 5 surgeons, 4 anesthesiologists, RNs, OT techs, helpers. This is the first mission to this location for our group, and we had little Eden what to expect, or what they where in need of. Today was all about learning just that. A little over whelming today, meeting staff, learning where the clinics and ORs where, and learning their rituals on Sterility, where and how to change scrubs, etc, etc. It is not our goal to reinvent every thing they are doing, but to see where they would like to learn and potentially improve.
I will start by saying they are Very well trained, over all EXCELLENT. But we do many things differently, a lot of that is based on resources they have available, as well as expectations of patients, both medically and culturally.
The staff has been exceedingly helpful.
IThey have three GYNs on staff that we have met so far. Lots of people are on vacation as it is the tail end of a 10 day festive, the largest of the year. I spent the morning in out patient clinic with one of the GYNs as well as a medical intern, that means first year out of medical school. We saw what ever came in the door, OB, GYN. Tremendous variety. Minimal equipment in the clinic, but easy to get labs and imaging quickly.
This afternoon we got to help with OR, they had 6 patients waiting for C-sections by 1 pm. Two where breech, one was a prior C/section, (they do not do VBACs if they can help it,) Our other OB did one section with the local OB, while I started about how on a patient with preEclampsia with another one of their House Interns. So we are slowly starting to gain their confidence, and their trust.
Tomorrow we have at least three Hysterectomies booked, they do not want to do more than that, so one of us will be in clinic, the other in the OR, and we will switch back and forth.
Will follow up with some details of our first three days of travel to get here and some touring of Kathmandu and Flight over Mt Everest in a future email, as well as some info on our group. Need to head out to a dinner with the the hospital administration tonight.
It is 0600 on wed, our third day. Was to tired yesterday to write.
We are starting to get into a swing, and being accepted and trusted by the local doctors. Being our first time at this location, it takes some time. Yesterday I spent time in GYN clinic with two of their GYNs, they used me as a consulting attending, meaning they wanted to run cases by me for opinion, especially those for incontinence as well as prolapse. We currently have ten patients admitted in the hospital waiting for surgery , as their policy is to admit immediately and hold them upstairs room till there is time to operate. We have 5. Cases scheduled for today. There is a big push to teach laparoscopic ( minimally invasive) Hysterectomies. As none of them have done that. Unfortunately they have minimal equipment, and to date have not been able to show us the few mandatory items we need to proceed with these cases. I am encouraging them to start with basic cases and work up their skill set, but it will take some time to work on this.
Today we will focus on Incontinence as well as prolapse cases if possible, as well as several pelvic masses.
This morning will be telling, as we do not want to get into cases that we can not complete, yet they are desperate to learn these skills. The GYNs share one rack of laparoscopic equipment with the general surgeons, and according to our Surgeon who did a laparoscopic gallbladder yesterday, it is barely passable.
We have worked on numerous infection control issues with the OR staff so far. As well as some surgical techniques that could be improved. They have read the recent articles, but are reluctant to institute some changes.
Yesterday I did three c sections for them as they where so backed up. They seem to like our technique, wether they adopt any changes will have to wait to see. My last case was a know Dandy Walker abnormality of the fetus. That means the scalp bones do not close and the brain protrudes from the back of the head, covered by skin only. I will spare you the pictures, but this was a very severe example, and we suspect the child will have a very poor prognosis. :(
Our group have melded together like mission trips always do, everyone looking out for one another, pitching in and really just trying to help out and get work done. See OP Med face book for up dates as well as details about participants.
Prior to arriving at Chitwan we where able to have a half day of tours in Kathmandu. We took an early morning flight around Mt Everest as well as all the 20,000 foot Himalayas mountains. Breathtaking, Spectacular, does not begin to describe it, and pictures do not do it justice.
We followed that with a tour of the city as well as of temples and an open Crematorium.
Very spiritual and moving.
So last night we had an end of mission ceremony at the hospital.
The surgical part of this trip has been frustrating for our group as a whole.
Although we have been readily excepted by our peers at the local hospital, there was very poor organization on the administration's end, in preparation for our arrival. The biggest effects of this was the lack of room for us in the OR. We had patients that we where not able to operate on due to lack of space. Usually when a mission group shows up, the local facility provides Space in the OR for "surgical camp" patients. In our case we had requested three rooms, one for GYN, two for general and plastic Surgery. We got None.
On the GYN side we were allowed to use the OB/GYN room, however all C sections also had to be performed in that room. With 2-6 c sections per day, there where days that we could not even get one GYN case done.
There where patients that we admitted for surgery on Tuesday that never got their procedures done. :(
On day 4 I was able to squeeze in three cases between C Sections. AND I had at least 3 Local GYNs present and or assisting with the cases. I had preformed enough cases prior that they realized I might be able to teach them some techniques. The most experienced local GYN has been at the hospital 5 years. Meaning she is barely 30 years old. They graduate med school at the age of 24, and then 3 years of residency at most.
Most of them have been there 1-3 years. Their surgical skills are solid basic, but nothing past that. We did some slings early on, for Stress Incontinence, and they where impressed. So when we had a patient with total Prolapse (Things falling out), they where all anxious to scrub and learn some new Skills. So unfortunately it took all week. But in the end I was really able to do a moderate amount of surgical skills teaching.
As an organization there will be discussions as to wether we come back to this location. As this was the first trip we did bring a relatively small crew, and glad we did. For there to be a future trips to this location there would have to be some pretty firm guarantees about availability of local resources.
So we ended on Thursday night instead of Friday, due to our inability to really work. We took advantage of the extra day to visit Buddha's birth place.
Lumbini, is about a 3-4 hour drive from where we are. The roads are beyond horrible, and you have to go up and down over a mountain pass. Barley two lanes wide, ditches on both sides, HUGE trucks in both directions, and someone broken down every couple hundred yards. Half the pavement is missing, HUGE ruts and pot holes that can gobble a car or bus. But it was worth the drive. Essentially a museum, a world heritage site, with Buddhist temples created from countries all over the world. So you get the Thai, Japanese, Sri Lanka , etc, version of Buddhists temples. There must have been 20 of them on the site, everyone different and amazing. We had a great tour guide, very knowledgable about all of them.
This Morning we went on a Safari Drive through Chitwan national Park, a wild life game preserve, about an hour from town. It is approx 900 square Kilometers. You can go for an hour, or 3 like we did, or go out for a week at a time. We saw tons of birds, deer, and monkeys, but missed the Tigers and Rhinos. A good time was had by all. This afternoon we are flying back to Kathmandu, spending the night, shopping in AM and flying home in the afternoon.
We get back to NH on Monday afternoon.
No regrets, wonderful experiences, and amazing memories, with an Incredible group of traveling companions.
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