Monsoon

Considering we are in Nepal at the height of the monsoon it has had very little affect on us. It normally rains at night and the main difference that we notice is that it becomes much cooler, which we are all very grateful for. However, there are two notable exceptions when the monsoon has lived up the reputation of being all-consuming.

Once was during our first week when it rained very heavily overnight. I had been vaguely aware of this having been woken briefly by the thunder and the lightning. I became far more acutely aware at around 5am when I was awoken to the sound of splashing and giggling. Laxmi giggles at most things and it was 5am, which is early even for here, and so I wasn't paying much attention and was hoping that she'd stop giggling and go back to sleep. However, when I rolled over to find the source of the splashing I realised it was because Laxmi was standing in the middle of our room which was covered with a good inch of water.

One of the benefits of sharing a room is that the girls had stopped me from putting my bags on the floor, they had not explained why but it was one of the many things that didn't seem worth arguing about. And now I was very grateful! Josh wasn't so lucky and so lots of his clothes got a free wash. Once they were hung out we started clearing the water from the rooms. All of the floors are concrete and so the water was literally swept back out of the doors and onto the balcony and from there drained outside. Concrete floors make the whole job significantly quicker (although not quick enough at 5am) but whoever designed the floors so that the rooms were an inch lower than the outside was clearly not having a good day. Luckily, however, this does not happen often. I still keep my bags firmly off the floor though.

The second time the rain caught me out was when I was walking back from the internet cafe. It is only a 30 / 40 minute walk over a flat road and in England I would cover this distance most days. Here it is the furthest that I ever walk simply because everything else is either too far away and you need to get a bus or, as most things are, they are closer. Therefore when I stepped out of the internet cafe and it started to rain 5 minutes later I realised that I was going to get quite wet.

The rain here can be light drizzle that is seen in England or it can be torrential downpours, frequently switching between the two with some fairly impressive lightening in between. This one was a torrential downpour and so I stopped at a shop to wait under cover with a drink while it abated. We have stopped at this shop before and the women seemed happy for me to sit there and wait for the rain, although it is always odd sitting and knowing that people are talking about you but having no idea what they are saying. It gives me a new appreciation for never talking about patients as if they're not there.

The rain eased off and so I headed back, but it was still raining sufficiently to mean that I was soaked by the time I got to the clinic. I had also been wearing flip-flops due to the lovely sunshine when I left so I returned looking like a drowned rat with mud splattered on my legs and back. Needless to say this set Laxmi off giggling but it did mean I got a cup of tea!

Wound Care

Chisang Clinic sees many patients, old and young, that need wounds taking care of. Some of these are minor things that, in England, would probably be sorted out by making sure they're clean, some germolene and a plaster. Some of them are more serious and would probably go up to A&E in England.

One such boy came in a few days ago. He came in limping, so it became apparent there was something wrong with his leg / foot. However, only when he sat down did we see the wound. On the back of his ankle was a cut about 2cm long and 2cm wide that had cut away the skin so that it came loose in a flap - a sheet of tin had apparently fallen and cut open the back of his ankle. It didn't look pleasant.

He seemed fairly cheerful about it until we started cleaning it. First with saline and then with iodine it was clearly a very painful procedure for him due to the depth of the cut. It didn't help that due to the awkwardness of getting to the back of the heel he was kneeling on a chair as I'm sure he must have been feeling slightly faint and sick. It is vitally important to keep wounds clean here and it is not as easy as it is at home. Therefore wounds are cleaned and then covered with iodine ointment, which is waterproof, to prevent infection.

One of the biggest contrasts that I have noticed in Nepal compared to England is how people react to injuries. Admittedly, I haven't done much wound care in England as I haven't completed my A&E attachment but children in GP surgeries scream at the idea of having their chest listened to. Here, people put up with what must be quite painful procedures with barely any fuss. This doesn't just apply to older people but to many of the children as well. I think they are aware that they are at the clinic because they need to be, rather than many of the children that are at the GP surgery because their parents are double checking. Therefore they know it is necessary and so put up with it much more stoically.

I was very glad for this boy's sake when the wound was clean and the bandage on although his limp did seem much more serious after it had been bandaged! It did mean his mum got a bike to take him home which, given the look of the wound, seemed fully justified.

Momo Making

The Lonely Planet describes momos as 'Nepal's unofficial delicacy' and, having tried them before, the steamed dumplings are very good. After talking about them a little with the girls they agreed to show us the process of making them. Little did we know what we were letting ourselves in for.

After purchasing the ingredients we started with the chopping. We started at about 3pm with three of the girls chopping vegetables and I was peeling garlic. Everything has to be chopped very finely for momos as it is more like a paste in the middle of the dumpling than chunks of vegetables. At home this is fairly easy as you can just put everything in a food processor. Here, everything has to be done by hand.

So, after much chopping we were ready to start assembling the vegetable momos. The chopped vegetables, garlic, ginger, spices and salt was all mixed together and then placed in the prepared dough. A relatively simple process that required a few stages - one person rolling the dough and then one person adding the filling. It sounds simple but each momo is 5cm big this had to be repeated many times. To speed up the process we had a each person working on one stage and it was a good effort of teamwork!

Even once the momos were prepared they take 45mins to steam until ready and so once the first round of momos were finished we were all getting quite peckish. And we hadn't even started on the chicken momos.

While we had been chopping the boys had been sent out to get the chicken and I don't think Josh was really prepared for what he had let himself in for. Electricity here is sketchy at best and few people can afford fridges anyway and therefore there is only one way to keep meat fresh - alive. When you go out to buy a chicken you buy a chicken that is still clucking and they kill it there in front of you and then chop it up for you. I wasn't aware of this and Josh certainly wasn't. He's now debating vegetarianism.

Once the chicken had been brought back it also had to be chopped into very fine pieces, and I was quite glad to be part of the momo making factory at this point. Once chopped it was added to what was left of the vegetable mixture and then the momo making started again.

Eventually all the momos were made and the mixture used up and we waited for the last of the momos to be steamed. By this point it was almost 8pm and it was a very hot evening! The momos were very good but I have to admit I'm not keen to make them again whilst in Nepal! It was a very long process that does produce delicious food but shows how different our attitudes to cooking are. It is difficult to persuade many people in England to cook a proper meal, let alone spend the whole afternoon cooking one!

Betana

There are many people that walk in and out of the clinic on a fairly regular basis and one of these is a young boy called Nakul Karki. We were talking with him about local wildlife and he seemed very surprised that we had never seen tortoises and so he took us on a trip to see them at Betana, a park near to Bhaunne.

Before we went into the park we bought two packets of crisps to feed this fish. I'm sure an environmentalist wouldn't be too pleased if they realised it is fairly normal for the children here to buy oily crisps and throw them into the river to attract the fishes and tortoises. The animals themselves, however, seemed fairly happy as for each crisp many fish came to the surface to fight over it. There were fish of all sizes, but some of them can grow pretty big - they were over a foot long and apparently can weight over 3kg!

Among the fish there appeared a tortoise, that seemed very serene among the mad fight for each crisp. Apparently some of the tortoises around here can reach up to 40kg, which this one certainly wasn't, but it was very graceful among the grappling fish.

Betana is a very peaceful place and there is also a lake where you can hire a boat for Rs100 (less than a pound) to row around. It was very warm in the sunshine and it was lovely to idle around the lake for a while and it was a good way to spend the afternoon. I think it was partly nice as we were totally off the main tourist trail and so there were no other foreigners there. That is one of the joys of living in a community rather than visiting, as you are able to visit places that locals know about but that tourists often miss.For the Nepalis there I think we were as much of a novelty as the park itself and I think we are the subject of a few of the photos taken by people visiting that day.

Jaundice

It is now nearing the end of my third week in Nepal and it seems to have gone very fast! I have settled into the pace of life at the clinic and, as well as seeing (the still few!) patients that come to Chisang we have also been visiting places around Bhaunne. Some patients are more memorable than others as, like at home, there are always certain conditions that will be more common than others.

One patient that has particularly stuck in my mind is a 13 day old baby that came in with jaundice. Jaundice is not uncommon in newborns and is normally nothing to worry about. However, it is less common for a baby to present with new onset jaundice at 13 days old.

This may still be a physiological response as babies who are breast fed, which almost all are here, are more likely to develop jaundice. At home this case would probably be referred on for paediatric review, just to be on the safe side. However, in the clinic, we are not able to do this. This is one of the cases where we have to rely on our own clinical judgement but also have to adapt to what resources the clinic has. At home we would probably run more blood tests to rule out more serious causes but, at the clinic, this is not possible.

In cases of jaundice the levels of bilirubin are monitored as they can become high and if the levels become too high then it can damage the baby's brain. This is made more complicated as the units they use for bilirubin here are different to the ones we use at home and therefore we were unsure what level of bilirubin is considered dangerous. The test was run and the results came back showing the bilirubin levels where raised, but Yamina assured us that they were not significantly high. As going to hospital is a very serious decision here that is not taken lightly this baby was not sent on for further testing and the parents were advised to come back and have the bilirubin checked in a few days time.


It is cases like this that highlight the real differences between the two healthcare systems. A trip to the hospital is free and generally easy in England and therefore people are sent there much more freely. We also live in a culture where everyone is scared of being sued and therefore doctors are likely to be more cautious rather than less. As we have been trained in this environment it did make me feel a little uneasy that we were doing nothing for him, especially as this would definitely be a case that I would ask someone more senior about at home. However, I think this is an important part of going on elective, to learn to trust more in your own clinical judgement in a situation that you have to adapt to. You are very much forced to work beyond your comfort zone, even if it isn't 9 to 5 work!

Chisang Clinic

We have now been at Chisang Clinic exactly one week although, as always, the first week feels like it has been much longer!

I have to admit our first night was quite intimidating as we arrived late on the evening when everything was dark. We met the four girls who run the clinic - Laxmi, Ulga, Yaumena and Duge - although at the time I could not remember any of the names except Laxmi. They did not speak much English on the first evening and we speak no Nepali. Neither me nor Josh really knew what to do or what to say and I went to bed feeling that I had no idea what I had let myself in for. It didn't help that it hadn't rained yet and even sitting in the breeze I was pouring sweat. It was an interesting night.

The next day, however, things immediately started looking up. It rained overnight which brought the temperature down to a bearable level, although still warmer than England. To start conversation I asked Yaumena to teach me some Nepali and she very willingly obliged and was very patient with my horrendous pronunciation. They have many sounds that we don't have and languages do not come naturally to me anyway, but she is a good teacher.

Over the past week the girls at the clinic have opened up immensely and their English is much better than we thought on the first night. Debendra (who set up and officially runs the clinic) mentioned that some of the volunteers have been less than ideal and, in hindsight, they were probably as wary of us as we were of them. If two total strangers were coming to live in my house for a month I would also be quite wary of them.

Now it is hard to believe we have only known them a week as everything has settled into routine nicely and they are extremely helpful with everything. They do laugh at many of our mistakes with language and helping with chores but it is friendly laughter and, to be honest, many of our mistakes deserve it!

The Clinic itself is set in Bhaunne, a rural village in south-east Nepal. The patients that come in the door can be anything and the Clinic is the first port of call for anything medical in the area and serves a similar function to a GP surgery in England. Treatment here does not come free and therefore it is not quite the same as at home. However, there still seems to be a huge variation in the wealth of those who walk in the door but often it is hard to tell.

The girls have been working here for at least two years and, although none of them are qualified as doctors, the coughs, colds, ear aches, tummy pains and things that make up a lot of community work they are fantastic at dealing with. Part of GP at home is also to provide social support for people and the girls also seem to provide this amply. While I don't understand what is being said many patients, especially the women, stay for much longer than a medical conversation would take and I assume they are discussing village life, gossip and the troubles people have at home or they see around them.

Since we have been here there have been a couple of notable cases that have come in that are outside the usual snuffly children or coughs. These are the cases were Josh and I can be useful. We are having a major crash course in speaking through a translator and it does highlight which questions are useful and have to be answered and which can be left out. We are also learning how to simplify questions to make them understandable and translatable. It also highlights the usefulness of examination, although this can be a challenge if you cannot translate what you need the patient to do!

There are fewer patients who attend the clinic than we expected and this is partly due to the heat as during the day it really is too hot to be doing much. Therefore we are keeping ourselves busy doing other things and there is lots of time for reading! Debendra is visiting in a week's time and he said there are cases that he wants us to review and this will be interesting. Partly to see the kinds of cases and also it may be a test of our medical knowledge, but I am looking forward to this.

I hope everyone is well at home and that the weather is getting warmer!