Sunday, March 06, 2005

and finally (for now):

Today, not having any specific plan, I find it difficult to get out of bed to make it in for 9 (yes, I know, hard to believe isn’t it?!), so I stay dozing for an extra hour. I say dozing because it is difficult to get back to sleep with such bright sunshine pouring through my window and the noise of building over the ‘road’. Obviously not your average British construction involving mechanical noisy things, but lots of banging and sawing nonetheless.

Finally manage to drag myself out of bed and into hospital by about ten o’clock and head straight to the emergency department to see if I can find anything much going on there. The emergency department is a relatively small room (10m x 10m perhaps) with a stone floor, tiled walls and trolleys pushed into corners. There is some complicated curtain system, but they are all tied up out of the way and don’t seem to correspond to the position of the beds anyway! One corner is walled off, and I imagine this is “resus”, or just an area with three or four beds affording a little extra privacy.

As far as I can work out, there is no “primary” or “family” health care (equivalent to GP) in Nepal, and patients simply self-refer. I think they have to pick up a ticket at the main door before they are allowed into the various corridors of the building, which are manned by security guards.

As an example of how this works, I shall use a lumbar puncture I observed earlier today. An elderly lady is brought in by her two sons, obviously unwell and with signs of meningism (fever, photophobia, neck-stiffness, etc) and her history is taken and a cursory examination performed by one of the interns (much like our PRHOs). It is decided that she needs a lumbar puncture to make the diagnosis and one of her sons is given a list of necessary kit, with which he promptly scurries off to the pharmacy. The patient is cleaned with iodine and draped with a “sterile” cloth with a hole torn crudely from the centre, positioned over the small of her back. From the kit her son brought back from the pharmacy, the doctor chooses a needle and syringe, and then draws up some local anaesthetic to numb the entry site. Having done all this, and in “sterile” gloves (taken using tongs, from a huge, shiny metal lidded pot in “resus”) the doctor then searches frantically for the spinal needle… It seems either it has been lost or was not included in the bag of stuff from the pharmacy. Eventually, the doctor has to send the son back to the pharmacy for another – there isn’t a supply in the emergency department! 10mins later, when the son has returned from the busy pharmacy, the procedure can continue!

As far as I can tell, there is no equipment in the emergency department other than a few portable cardiac monitors, ECG machines and portable, mains-powered suction contraptions. No needles, syringes, bandages, medications or any of the other paraphernalia which overfills storage in your average UK Accident and Emergency Department.

I spend the whole day following the senior doctor around the room, from patient to patient (in no particular order it seems) and listen to medicine in a foreign language. Occasionally, the barrage of “derka derka jihad” is punctuated by one symptom in English and I am asked to come to a spot diagnosis. This is a little unfair I feel as I don’t get to cross-examine for ten minutes like he does! At least now I am getting used to the accent and can tell when I am being spoken to in English. Medicine is taught here in English, it seems, and when doctors talk between each other it is in a mix of Nepali and English – so, often, I can understand the gist of it at least!

Today’s mix of patients included (apologies to my non-medical audience):
· A girl in her twenties with moyamoya disease
· A 50yo gentleman with a silent anterolateral STEMI
· An elderly lady with meningitis
· A 5cm x 5cm meningioma in a 35yo female
· Only one case of trauma – a “physical assault”, involving a fractured base of skull

There are a constant stream of patients walking through the door, must of whom have significant pathology; I am impressed by the relative absence of malingerers – a refreshing change from the NHS. But I suppose if we had to pay for every single blood test, investigation and pill, perhaps time-wasters may be deterred to the same extent in England?!

Just out of interest, a standard plain x-ray costs 200 rupees and a plain CT is 2000 (132 rupees to the pound). It costs 25 rupees (the same amount I pay for lunch today) just to get a ticket to be allowed into the department!