Outpatient Department

The outpatient department (OPD) is where all the surgical services at TUTH conduct consults and follow ups. Each service has 2-3 / week at approx 2-3 hrs each. Clinics are crazy busy and I'm not sure there are appointment times. It seems everyone shows up for OPD X, register, and then cluster outside the door waiting to be called. So far I've been at OPD with GI team 3 and neurosurgery (which I just started with yesterday).

Within the clinic equipment is old and worn but familiar. Encounters proceed in the usual fashion: history, focused physical exam, and plan. Biggest change is that whereas at home there would be one exam room per patient, here 2-3 doctors would sit at one desk interviewing one patient each - there is no concept of confidentiality. Privacy is protected by a drape in front of the examination table.

As elsewhere in TUTH, cleanliness is lacking. There is a sink but I never saw it used. There is also no paper or sanitation of the examination table between patients. The one exception to this is a neurosurgery resident who carried hand sanitizer and was good about using it between OPD patients.

Desk in OPD. A doctor sits at each blue chair and each interviews a different patient.

Examination table

Pathology

In terms of pathology there is the same mix of hernias, gallstones and anorectal problems found within general surgery in Canada. Since the GI team also does minor procedures, lipomas and sebaceous cysts are also common.

Pathologies common here but rarer at home include:

- acute pancreatitis

- gall bladder cancer

- tape worm

- liver abscess

- tuberculosis and its systemic sequelae

- necrotizing fasciitis

- diabetes type 2 in people with normal BMIs

- extra hepatic portal venous obstruction. (which is considered a diagnosis here though I was unable to find mention of it in the western literature)

- infection in general

Miscellaneous observations

During a break in the OR today, I thought I'd share some observations that don't fit well elsewhere.

1) Calendar

Nepal uses a different calendar for work. In Nepal it is presently the 24th day of the 8th month in the year 2070. It's a lunar calendar 57.7 years ahead of the Gregorian and apparently founded by an Indian Emperor after a battle. It is different from the Indian calendar which is 78 years behind the Gregorian.

http://en.m.wikipedia.org/wiki/Nepali_calendar

Combination calendar. Also handy for learning to read the numbers.

2) Patient Age

Patients are relatively young. A 70 year old is elderly in Nepal. Very different from the 80 and 90 year olds I've regularly cared for in Canada. A combination of hard manual labour, poor preventive medicine, and late presentation to hospital when ill I'd imagine. Official life expectancy is 68 according to the World Bank.

http://data.worldbank.org/country/nepal

3) Phones / Ethics

Smartphones are very common with the doctors and residents.  In a hospital with film imaging the camera offers portability and quick recall for images. The phone also allows quick contact between doctors in a hospital with only overhead pages - there are no pagers like we have in Canada. Overall the smartphone use makes for more efficient care, but at the cost of patient confidentiality. This lack of respect for patient confidentiality is pervasive: hallway consults / updates, photos of pathology without asking consent, and multiple consults per room at the outpatient department. Only once did I see a staff ask families to leave the ward during rounds.

For those curious Android is easily in the majority. Very few iPhones and only one Blackberry and one Windows phone.

4) Blog Format

This is my first blog so leave a comment on what you like etc. Especially true for formatting / technical issues like the email subscription - I have no idea if they're working! Also incidentally most of the posts are being done with the mobile version so there may be some strange autocorrects.

Tour of Accommodation

Here's some photos of where I'm staying. A bit above the average Nepali home I'm told.

Outside. I'm on the second floor. The window to the left of the balcony is my bedroom.

Stairs up

The TV room

The washroom

Eating room

The kitchen

My bedroom. There is a second just like this in the apartment

NCCDF offices

Outside courtyard and gate.

SAARC Surgical Conference

Last Thursday I had the opportunity to attend the annual SAARC Surgical Conference here in Kathmandu. SAARC = south asian association for regional cooperation and includes Afghanistan, Bangladesh, Bhutan, India, The Maldives, Nepal, Pakistan, and Sri Lanka.

Day 1 of the conference was live surgery demonstrations. This took place at Grande Hospital, a recently built private around the corner from the Teaching Hospital. Facility wise it felt far more like a western hospital than the teaching hospital. I was later told that rich people leave the country for healthcare, upper middle class would go to a private facility like grande hospital, lower middle class to TU Teaching hospital, and the poorest to Brie (sp?), another teaching hospital in the city.

Main Enteance

Presentation hall

Day 1 agenda was live ERCPs. ERCP is for gallstones and is normally done by gastroenterologists in Canada (and most of the world). Here the surgeons do them. After the ERCPs there was supposed to be a laparoscopic bowel resection but the scheduled surgery was done emergently the night before and, being a private hospital, there wasn't a waiting list from which to schedule a different patient.

Throughout the live cases I was reminded of this article (), which argues live surgery is performance theatre, compromises patient safety, and that the principles taught are better done via video highlights. After my experience here, including the audience clapping the surgeon, I'm inclined to agree.

Evening of day 1 was the opening ceremonies at the Radisson Hotel. Like the Grande hospital, It felt very western. The opening ceremonies were attended by Nepal's Vice President and filled with a lot of pomp and circumstance. It went one for 2.5 hrs!

Hall at the Radisson

Vice President of Nepal

Day 2 was presentations at a local business tower. The day was divided into several sessions scheduled with a keynote speaker, then other papers. Keynotes were generally well done - I especially enjoyed one on surgical education in SAARC countries, as well as the talk from a Pakastani neurosurgeon. He discussed the changing face of trauma in the area: terror now causes more trauma cases than motor vehicle collisions. He also apparently treated the man who fired the SAM missile at te US SEAL helicopter during the bin Laden raid

Lobby of the business tower. Could easily be any major city.

The papers themselves were interesting. By and large they duplicated work previously published in the Western literature but in a SAARC setting. Many were done as part of the graduation requirements for the 3rd year residents (final year of MS). Studies were generally prospective case series. Discussion of statistical power was absent, as we're attempts to match patient backgrounds etc. Mention of ethics approval for research was rare and I don't know if that is a requirement for studies here. The discussion section generally focused on a review of the literature and how the presented paper compared. Limitations were inconsistently cited. Overall the papers felt more reflective on individual practices in SAARC nations than the novel papers advancing the field found at the American College of Surgeons Congress. This work is no doubt important, especially reproducing scientific results, but made for less interesting papers. I'm reminded of the recent Economist article highlighting how major studies are no longer checked for reproducibility and negative studies harder to publish. It certainly is more interesting to read / watch novel papers.

Along with the presentations, there were the usual vendors / advertisements. Vendors tended to be local distributors rather than manufacturers. There were even ads for antibiotics!

Vendor with even basic surgical instruments profiled.

Antibiotic ad!

Day 2 ended with a cultural program of formal traditional dances. After there were snacks and drinks. Some of the residents also started dancing on stage - a mixture of traditional and western. I joined in but have no photo proof. I'm sure someone does though - I was the only Caucasian in the room!

Traditional dance

Dancing after

Day 3 of the conference was on the Saturday, the only weekend day as the work week is 6 days. Consequently I skipped attending more paper presentations and went touring. But that is for another post.

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.