Medical Elective Report: Fiona Huang

MEDICAL ELECTIVE REPORT FIONA HUANG. NEPAL 2014 This summer, I received ÂŁ200 from the Selwyn Medical Elective Fund to help me undertake a 5-week trip to Nepal with the Mountain Trust with three other medical students in my year. We planned to spend our time there participating in rural health camps, gaining hospital experience at the College of Medical Sciences, Bharatpur, and doing some health and hygiene teaching at secondary schools.

We arrived at Kathmandu early in the morning of 26th July, but decided to go to Bharaptur, Chitwan as soon as possible to meet with Dr Iype Cherian who is a neurosurgeon at the College of Medical Sciences. While we were there, he taught us about a neurosurgical procedure he has pioneered called cisternostomy. It is a new surgical treatment for traumatic head injury with the same indications as that for decompressive hemicraniectomy, found to decrease intra-operative brain swelling, mortality and morbidity. https://www.youtube.com/watch?v=HRSHHvVGZpQ We also observed some operations while on a night shift with Dr Cherian. The operations would run throughout the night, and it was amazing to see how the surgeons managed to maintain their keen concentration and dexterity even at 4am in the morning. We saw a bifrontal skull fracture in a 15 year old male, who had a traffic accident while on a bicycle earlier that day. Luckily, his superior sagittal sinus was not damaged and the brain was relaxing and pulsing so there was no cause for concern; the surgeon just had to reconstruct the bone flap.

During our 2 week stay in Bharatpur, we also spent time in various departments such as General Medicine, Neurosurgery and A&E. It was really interesting to see just how different the disease prevalence was in Nepal. In the General Medicine ward, there were many more infectious diseases presenting, such as TB, sepsis, and Japanese encephalitis. In the emergency ward, there were cases that we’d be more familiar with such as COPD and ischaemic stroke, but also more unusual ones such as hyperglycaemia from undiagnosed diabetes and attempted suicides. Many of the diseases were presenting in the very late stages since the first port of call for many Nepalese (especially the less educated) when they fall ill is to see a priest or shaman. Coming to the hospital can be a last resort. Our stay at the emergency ward with its fast turnover was a real insight into the epidemiology and culture of Nepalese people, from a health perspective at least.

During the last few days of our stay, we teamed up with another group of volunteers to help out with a health camp happening in the village of Madi (about 3 hours away by bus). Some doctors from the hospital had kindly agreed to volunteer to take part in the free health camp for villagers in remote areas, and we piled the medicine bought with funds we had all raised back home into a bus and braced ourselves for the 3 hour journey over dirt tracks to Madi. We were planning to have our base at a local school and there was a big crowd outside when we arrived. We all split ourselves into one of the 7 specialties represented that day, of which I chose Obs/Gynae. Our office was a wooden shack on the school grounds, and the team

consisted of a consultant, a senior registrar, and 2 volunteer medical students. We two medical students were tasked with conducting a basic external examination checking for anaemia, jaundice, clubbing, cyanosis, oedema, lymphadenopathy, and dehydration. I also had the opportunity to take a lot of manual blood pressures and at the end of the day, I was pretty confident at examinations through sheer repetition!

We saw many infections and the doctors prescribed a lot of antibiotics.

However, we didn’t know what the infection was, or even if it was definitively a bacterial infection. It was no surprise that antibiotic resistance levels were rising with such casual prescribing, but we did see the difficulty of trying to identify the bacterial infection for every single woman, considering many of them were only here for the day and we did not have the lab resources to do so. Even though we were in obs/gynae, the women presented with any complaint that was in the epigastric area as well, and as a result we saw many gastritis cases. These are very common in Nepal, due to the very spicy diet that is low in fresh vegetables, and also the irregular meal times. One thing that shocked me most was probably how long some women had lived with their presenting problems for - one had pain in her left loin for 7 years, which the doctor suspected was kidney stone. There were a few women who required further tests at the hospital, including one potential cancer case. However, visits to the hospital and diagnosis takes money - not only for the procedures themselves but also for the journey there and back. We hoped that the women would listen to the advice and follow up at the hospital, but we won’t know for sure.

We also took part in health camps when we were in Pokhara, which were similar in structure, even if the number of specialties present differed. I helped out with the orthopaedics and general medicine specialties, where I saw a lot of occupation-related conditions. Many people who came were farmers so they would present with osteoarthritis of the knee, tennis elbow and other conditions associated with general wear and tear. It was interesting to see how different the doctor-patient relationship is in Nepal, where the doctor took a very paternalistic role and patients decided either to follow his/her exact advice or not.

In Pokhara, we spent most of our time teaching at Balmandir Higher Secondary School. The students there were aged 13-16, and we taught mainly sex education and biology, including a health series on non-communicable diseases. I was probably the most tired I had been on our trip thus far, since we had scheduled lessons for all 7 periods every day, and my voice was fading by the end of the day!

The classes were large (35-45 per class) and we had to learn very quickly how to manage them and keep them interested. In sex education, we were really surprised that a lot of the girls did not know why they bled every month, and what menstruation was. We really had to go back to basics and explain everything from puberty onwards. In some classes, the girls got very embarrassed and refused to interact, whereas in others they were really keen to learn. The boys were always very interested and constantly egging each other on to ask us their burning questions!

The Q&A session we ran was very successful as the students got to anonymously submit their questions to us.

The non-communicable disease (NCD), series we did centred on the big 3: cardiovascular diseases, diabetes and cancer. Their teacher even sat in on our lessons which had the general format of first introducing the topic, then discussing

the lifestyle choices which put you at greater risk, as well as genetic factors. We wanted the students to know why certain lifestyle choices such as smoking, alcohol, and a poor diet put them at greater risk of certain NCDs, so we taught them (the simplified version of!) the physiological and pathological basis behind the diseases so they would understand and remember better. It was a really popular series that the students requested to run into their leisure periods and they had many general questions too about the transmission of diseases (especially Ebola!) as well as questions about mental health. It was pretty obvious that they had not had anyone in school or home to whom they could ask these sort of questions.

Overall, my time in Nepal was spectacular. I went home exhausted on most days but the learning experience of seeing healthcare provision with limited resources, as well as having the opportunity to provide health education to young people who needed it has been invaluable. This is especially true in my case since I had already had an interest in both areas, and this trip to Nepal has affirmed and inspired me to further pursue them.

Class 10B at Balmandir higher secondary school

Queuing outside the Madi health camp

Outside the Obstetrics and Gynaecology Clinic

Monsoon season scenery from the coach

Case of clubbing seen at Pokhara health camp