Clinical Work

One week in... hard to believe!

Upon arriving here I was assigned to Gastrointestinal (GI) Team III. The team is headed by a senior surgeon who has the designation Prof. Under him is the junior faculty, then 2 senior residents, 1-2 junior residents, an intern, and occasionally MBBS students.

For reference, as best as I can tell the curriculum for general surgery is:

• 5 years MBBS (bachelors of medicine and surgery) directly from high school
• 1 year internship
• 3 years MS (Master of Surgery, includes a thesis) -> this is approximately a resident level PGY1-3
• ? MCh (I think? not sure after this)

As 4th year MD in Canada I seem to fit in somewhere between the 1 year internship and year 1 of MS.

GI Team III's schedule is:
Rounds daily 8am, followed by presentation / discussion of the overnight cases with the other GI teams. The bulk of the day is filled with ward work, but each day has some specific Tasks as per below:

• Sunday Outpatinet Department (OPD) pm -> yes, Sunday is a regular workday
• Monday OPD in am
• Tuesday - ERCP
• Wednesday Operating Theatre -> it's called OT here, not OR.
• Thursday OPD
• Friday Minor OT -> lumps and bumps but includes hernias under local anaesthesia

Ward work is quite different from Canada. After rounds there will be a page in the Round Book that details the plan for each patient for the day (analogous to our "lists" but only the plan. By and large everything in the plans fall to the junior resident and intern to implement. So dressing changes which the physicians rarely think about on a daily basis in Canada become a significant part of the day here. The process for maintaining sterility is also quite a bit different - > I will try and write a post specifically on dressing changes with photos later.

Other ward work will include filling out laboratory and imaging requisitions. For lab work tests are ordered entirely individually. So where we would order CBC +/- differential, the individual components have to be ordered - Hb, WBC etc. Within surgery the nurses actually draw the blood, but apparently it is the interns / residents who draw blood on the medicine rotations. Once labwork is drawn (or pathology is excised), it is the responsibility of the patient's family to deliver the specimen to the appropriate location. Tribhuvan University Teaching Hospital (TUTH) where I am based is quite large and many patients are from rural areas - samples becoming lost or not arriving appears to be a semi regular occurrence.

There are several aspects of the wards that stand out: they are wide open and there is no sense of privacy. It's the role of the patient's family to set up drapes for privacy during dressing changes. Windows are left open and flies freely move about the unit. Floors are dirty reflecting the dust from the rest of the city. Hand washing on the wards is virtually non-existent and there is no alcohol hand rubs to be found. Access to sinks / soap / hand sanitizer improves in the ICU and post operative ward (for immediate post-op patients), but compliance appears to be poor due to poor habits from the rest of the hospital. Nosocomial infections (picked up from the hospital) are common and include broadly resistant bacteria, and miliary (systemic) TB on the respiratory ward.

Post op ward bed. We had to take our shoes off to enter this area.

Nursing station. The charts are the steel clipboards.

Ventilator in post op ward

A significant change from Canada is that patients are required to pay for almost everything at the hospital and there does not appear to be any insurance schemes available. I believe that TUTH is partially government supported to allow its existence, but all patients are still required to pay for services and equipment. Today during dressing changes this actually created a significant delay: we needed to remove an incisional drain, but had to wait for the patient's family to walk over to stores and purchase sterile gloves. This also means that patients purchase all disposable supplies for surgery and bring them to the surgery in a bag. Medications are purchased in a similar manner and while a nurse administers them, the medications are kept in a basket by each patients' bedside.

A patient's collection of surgical supplies purchased for surgery, on the floor in the OR

Some sample prices include: 25NPR for sterile gloves, ~100NPR for a bed (see chart below), ~10000 NPR for a surgery. Average income is 3500-5000 NPR/month. 1NPR ~= 0.01 CAD. See below link for an idea of other prices.
http://www.thelongestwayhome.com/blog/nepal/how-much-money-does-a-person-from-nepal-earn/

Comparing with the intern Yeshey who is from Bhutan is interesting. In Bhutan the healthcare system is fully publicly funded but low resourced. People will still go to the doctor for even very minor concerns, much as they do in Canada. Here in Nepal because the cost is directly on the patients, preventive medicine is rarely practiced and patients present late and more acutely ill.

Outside of the hospital there are at best minimal (possibly none?) controls on medications. Most of what we know as prescription medications are available over the counter. This unfortunately includes antibiotics leading to a high rate of resistance. Meripenem and pip-tazo are the first line for new infections of unknown etiology. I've seen a patient sent home on cefixime (in Canada  broad antibiotic that would rarely be used at home).

Final thought: While English is the "official" language of work, in practice this means it is the written language - all verbal communication clinician-clinician or clinician-patient  is in Nepali. Unfortunately this significantly restricts by ability to be involved in care and I spend large amounts of time observing. Still a great experience though!

Phew! Super long post. I hope it helps provide a better sense of the clinical environment here as well as the "typical" work days. I'll try to elaborate on some specific areas later. Also to come: conference from last week, sight seeing from Saturday.