DHULIKHEL

Week 1 

I was collected from Kathmandu Guest House by a Hospital vehicle – a very comfortable 4x4.  The journey to Dhulikhel took about 1 and a half hours. 

Dhulikhel sits approximately 400m above Kathmandu and has amazing views of the Himalayas.  It sits on the main highway and the streets leading off it are wider, smoother and much quieter than Kathmandu.  Away from the main town it becomes more rural very quickly and walking here I will see mainly countryside and farming areas.

The back of the guesthouse my room is 3rd floor up window on the left

my room

Nabil Bank- Entrance to the guest house

I arrived at the guest house which is three floors down from Nabil Bank, and 2 floors and a world away from the rooms I had been taken to with Sarah and George!  There are about 7 rooms each with its own bathroom (complete with western toilet).  Min Bahadur is the manager and he provides breakfast and evening meals from the kitchen managing with nothing more than 2 gas hobs, there is no oven. 

Min

Min cannot do enough to make us happy and his intentions are good.  He has a book that we write in each day to say what we want to eat and what time we want each meal, and this will be the basis of our bill at the end.  He seems to not then refer to it again, so my muesli and yogurt at 7am becomes egg toast after we have woken him up at 10 past 7.  I am sure it will all work out in the end though and he is really a very lovely guy.

Also staying in the guest house is Charlotte a Dietician from Luxembourg who is here until March with the hospital and then stays to play in Nepal until the end of May.  We get on well and I am very pleased to have her around at work and in the guesthouse.  She already speaks 5 languages; French, German. Luxembourgish, Spanish, and English, and with this natural talent she is picking up Nepali really quickly – I however am not!

The temperature here is hot during the day, although not as warm as Kathmandu and cold once the sun has dropped.  Now I am wearing trousers and a long sleeved top for indoors, but lunchtime sat in the sun is baking hot.  The sun drops at about 3pm and then indoors it is very cold – fleeces, scarves, heaters and hot water bottles required.  It does get to a point where outside is warmer than in, particularly as there is no heating.

The hospital is spread over the hillside and occupies a large area.  Over the past few years there have been great developments and where there were paddy fields as far as the eye could see, there are now new buildings and staffing accommodation popping up.  The building is of good quality and looks very smart.  Most of the usual departments are here; Internal Medicine, Paediatrics, ICU, Surgery (upper and lower GI), and orthopaedics.  Most of the support departments are also represented, with laboratories, microbiology, radiology, parasitology (!) and of course physiotherapy.

Library building on left and Teaching block on right

Further down the hill are the university buildings, KUSMS which have classrooms and practical rooms allocated to each subject.  The library is small, and is gradually improving there was even a copy of Physiotherapy (CSP UK edition) on the shelf.

One of the first mornings I attended morning conference which is where representatives from all departments meet to inform everyone else which patients have been admitted and to report on the existing patients.  This meeting is largely in English, and is led by the chief doctors, Dr Koju and Dr Ram.   I was really surprised at how technical the language was that was used – I had expected it to be simplified as the 2^nd language, and I was also surprised at the range of conditions and surgeries that were being conducted.  They exceeded my expectations.  

The wards were as I expected.  They are much more basic than in the UK, and practices are occurring that we have put a stop to, such as nurses coming into contact with blood and not wearing gloves, going from one patient to the next with no antibacterial measures in between, and being bear below the elbows.  Uniform white coats have just been introduced, but they are all long sleeved.  Before entering ICU we have to change our shoes, and wear a full gown and face mask, which is good, although the gowns are shared between staff and between patients, so in some ways it defeats the object.

The physiotherapists visit the medical, surgery and ICU wards every day and see every suitable patient, and their underlying knowledge is excellent.  There are many barriers to care and knowledge here.  Internet access is limited and so collecting evidence based material is difficult.  Resources are tight, so for example getting a post-op patient out of bed day 1 is difficult when all they have to sit in is an uncomfortable plastic chair.  The doctors seem to have a very prescriptive view of physiotherapy and it is not always easy for the physio staff to make their case.  The patients pay for care here and the general education level of the majority is very low.  This means that they do not understand preventative management, they do not see the benefit of getting out of bed and moving around when they are ill, and when things deteriorate then do not understand that medicine cannot work miracles.   I have seen families getting aggressive and blaming the medical teams for the death of their relative (not unlike the UK!).  Indeed when people die the family are brought in immediately so they can see the drains and Lines and oxygen lying around the bed space as this is one way to show them that everything was done to help.  Patients often would rather spend their 200rs on medication rather than physiotherapy which means utilisation of physiotherapy services is lower than I had expected.

The caseload here from a respiratory slant are post-op patients, COPD, Bronchiectasis, Asthma and poisoning which is extremely common, both accidental and purposeful.  Organophosphate (OP) is readily available to the farmers and when life is that tough sometimes they use this as the way out. It causes multi-organ failure.

The main aim of the first week was to establish exactly what I would be planning to do during my time here, there is so much that could be done, but I have time limitations, I am also well aware that change is slow and having only 2 months is likely to mean that some projects may not complete before I leave.

The key people I will be working with are Sumana and Sachit, who the current lecturers on the Bachelor of Physiotherapy course, and also cover the clinical caseload on ICU.  Krishna is a newly qualified physiotherapist who covers the Medical ward, and Jabina covers Surgical.  Ranjeeta is in charge of the course.  The rest of the department is made up of outpatient, orthopaedic, Neuro and Paediatric physiotherapists.  There is currently another fly-in here called Michel, a Dutchman from Austrailia.  He has been here since February and has a more over-arching role to improve the department as a whole – he leaves when I do in December.  The staff team are extremely welcoming and friendly, and are working really hard to produce a quality service and course.

The team from the left: Bimika, Shova, Michel (behind), Deepa, Krishna (behind),  Jabina, Nischal (behind), Inosha, Sumana, Ranjeeta, and the tall one is me! 

There are currently 2 physiotherapy courses running.  There are 13 3^rd year students who have previously completed the certificate course and are now converting to the bachelors – they have all been practicing physios in between courses and have more experience.  The other course is the 1^st year Bachelor course and these are all high school leavers.  All students are Nepali and all teaching is done in English (most of the time).  The learning style is very different here and I can really see the difference between Nepali and UK students.  Here the facts and knowledge base are absolutely sound, so when asked a factual question the entire class will accurately respond.  Challenge them to apply this theory, and to use their clinical reasoning and the response is less solid.  This feels a direct opposite to the UK where clinical reasoning is promoted and well developed, and often knowledge base is the lacking area.

This week as also sports week, where the students play basketball and football against other student teams – I am pleased to report that our boys and girls won both!

The main aims for my time here will therefore be based around development of the curriculum for respiratory.  Encouraging forward planning.  Supporting the staff development, and developing out patient respiratory care.



Garden of Dreams

Dasain swing

Friday night I took the bus into Kathmandu and stayed in KGH.  I pottered around in the morning and then met Sue for lunch in the Garden of Dreams.  Sue lives in Patan with her husband Al and they teach at the international school.  They’ve been here for 3 years and I have got in contact with them through my “cousin” Bex who used to work with them in Reading.  The Garden of Dreams is a haven in the middle of Kathmandu.  It was built in the 1920’s by Field Marshall Kaiser Shamser who modelled the gardens on those he had seen in Edwardian England.  It is manicured and comfortable with ponds and pagodas. Sue and I had a luxurious lunch and cocktails and then played on the Dashain swing set up in the garden which was top!

Early morning views

Namobouddah from afar

 Sunday was spent hiking up to Namobouddah with Michel and Gill his girlfriend, who is an Irish physio who now lives in Australia.  We left at 6am so that we would arrive in time for the morning teaching session and the walk took about 3 hours.  This was a particularly special session as it was being led by Thrangu Rinpoche who is one of the key spiritual leaders in this branch of Buddhism.  We were allowed inside the main temple and we sat on the cushioned floor with all the other monks who really didn’t seem to mind that we were there.  We knew that the session was going to be translated into English, but we didn’t realise you had to take a radio to hear the translation so the upshot was that we sat for over 2 hours listening to Rinpoche read Nepali from a book.  This was pleasant apart from the occasional hack, cough and spit into the microphone!  Despite not knowing what he was talking about, the atmosphere was lovely and the chanting done by all the monks together at the start and the end of the session was quite hypnotising.  I am glad we stuck out the full session.  The session as also available on the website so on return  from the walk I listened to it and it seemed to be a lot about digestion and how to keep it healthy and how this affects you spiritually – maybe a good job we didn’t hear the translation?! 

Preyer flags at Nomobouddah

 

Views from Namobouddah

Sunday was spent loitering around Dhulikhel working out which shops were available and I also put in the order for the dress to be made from the material I had purchased in Kathmandu – to be picked up after Tihar.




Week 2

This week I made some headway with the planning of the clinical placements for the course.  The team is not so good at forward planning, they work more in the moment, and when I presented the 5 year forecast for the number of students they will be taking and the number of placements that will be required against the number of places they currently have there was definitely a sharp intake of breath.  They will be quadrupling their student numbers once the course is full which shows their success.  I feel that I am really settling into the department and I am building a some really lovely relationships.
 

Friday night we took the hospital bus into Kathmandu stayed at KGH.  An Israeli friend of Charlotte’s called Niv joined us from trekking in Lang Tang.  He also volunteers at the hospital as an intern doctor.  Although we were tired we made the effort to meet up with Sarah a student doctor who had volunteered at the hospital previously, before travelling around Nepal.  She was back in Kathmandu to meet her boyfriend who was coming out to join her.  She had called us from Dubur Square where there was an end of festival concert taking place.  Jazzmandu is a week-long festival that showcases Jazz musicians from all around the world in Kathmandu.  The stage set up in the middle of the square, complete with flashing lights and a DJ was incredible.  The Nepali crowd were going mad to a band called No Jazz, a French band dressed in peculiar outfits including a DJ dressing in an all in one foil suit!  The music was excellent- and there was a saxophone as well which pleased me!

Saturday morning was taken over with the best massage I have yet had here.  We took a cab to a Spa  where the beds were heated and the massage was amazing and lasted for more than 1 hour – feeling very chilled, and a little oily we made our way back into Thamel to shop for gifts to take to Min’s family for Tihar.  This turned into a bit of a shopping fest - 2 cashmere jumpers for £14, Niv bought a north face coat for £25 – bargain. After treating ourselves to a good coffee and sandwich at Java coffee, we headed back on the bus to Dhulikhel. 

Sunday was spent pottering around Dhulikhel and catching up on mundane jobs.  In the afternoon I went for a wander in the paddy fields and took a good book to read.  This time of day it is warmer outside so sitting in the sun to read was perfect.  Whilst sitting there I was joined by an old Nepali woman who had come up from the fields.  She sat down gave me her sickle and rested her hand on my leg.  Anywhere else in the world that would be a reason to get up and leave, but here this is quite usual – physical contact like this is to be expected.  She spoke to me in Nepali and I replied in English and we got nowhere, but it didn’t really matter.  The only thing we managed to understand was “Dhulikhel Hospital” which is pretty universal here.  When the sun went down and it got cold outside too, we both went our separate ways.

 

Today Jonas arrived to stay in the guesthouse for the next month, he is a final year medical student from Germany.  With Niv's return, this made our guesthouse group now 4.................