Siân Maguire
Nepal Medical Placement

About Siân

Siân is a junior doctor working in the NHS. She completed her medical degree at the University of Bristol, graduating with merit. As part of her training she had placements at a variety of hospitals in South-West, rotating through different departments and specialities.

During Siân’s undergraduate years she also completed research in the fields of paediatric oncology and neurology. Her current clinical interests are Emergency Medicine, medical education and public health.

Preparing for a medical elective

“Where are you going for your elective?” must be one of the most asked questions amongst final year student doctors (closely followed by the clichéd ‘What time are you going to the library?’ and ‘Do you want to grab another coffee?’). Going on elective is often viewed as the highlight of medical school, and a reward for completing the 5 long years of university.

Medical elective placements are the opportunity for students, having passed all their exams, to experience medicine in a different healthcare system or setting than the one they have trained in. It is entirely student choice, so the options are endless with regards to where in the world you go, and what medical specialty you want to experience, for example cardiology, neurology, surgery or general practice.

Medical students must rotate through these different specialties during training. Some placements may only be a couple of weeks long, so electives are a great way to spend more time exploring your areas of interest. Electives are entirely self-funded, and within the UK there are many excellent options, ranging from getting involved in lab research at leading universities, to wilderness medicine in the highlands – making the option to stay in the UK an increasingly popular one. However, I wanted to try and travel abroad, and see how things were outside the UK and NHS.

During my search, one of my friends sent me a link to a medical elective programme in Kathmandu. After a quick look on Google maps to find out exactly where Kathmandu was, and having a scroll though Lonely Planet, we decided to go for it before we had time to overthink. The elective programme offered placements in Tribhuvan University Teaching Hospital, and a range of placements in emergency medicine, paediatrics and surgery, as well as offering a ‘rural healthcare week’. It was just days between looking at the programme and having our places on the 4-week programme confirmed.

As our departure date drew closer and exams and deadlines were ticked off, I got in touch with Nigel and the team at the Rohan Worcester store to see if they could help me out with finding some suitable kit. I had travelled in and around Europe before, but had never ventured further afield and wasn’t sure what clothing I would need.

We had been warned that village week would be very remote and involve trekking, but I also needed clothing smart enough to wear in the hospital environment. Along with this was the requirement of having to wash everything by hand only, the hugely variable climate within the country, and having to cram all my clothes into my backpack alongside my medical equipment.

I had one 60L backpack to fit everything into. These needs were miraculously met by the clothing that Nigel and the team in the Worcester store helped me choose. Siân (not me, but a fellow ‘Siân’ who works in the Worcester store) picked out versatile pieces from the insect shield range, and chose items that I could mix and match into coherent outfits that would be practical but still look smart and put together.

Clothes+

Underwear x10
Bra x3
Socks (mixed)
Vest tops x4
T-shirt x2
Casual linen blouse x1
Casual linen dress x1
Linen trousers x2 (green/navy)
Scrubs x1 set
White coat x1
Rohan Tian Shirt x1
Rohan Sanctuary Shirt x1
Rohan Hooded Trail Top x2
Waterproof jacket (light) x1
Rohan Trailblazers x1
Rohan Tour Chinos x1
Buff x1
Hiking boots x1
Sandals x1

Kit+

Lifestraw bottle
Stethoscope Sphygmomanometer
Own meds (prescriptions)
Oxford Handbook of Clinical Medicine
Disposable gloves
Masks (surgical and pollution)
Sanitising wipes
Alcohol gel
Snack bars
Glucose tablets
Quick dry towel

Other+

Book
Sunglasses
Earplugs
Travel adaptor
Phone charger
Money belt
Spare phone
Hairbands & clips
Day backpack
Notebook & pen
Paperwork
Passport
Cash
Swimwear

Kathmandu Hospital

Although lacking in many of the resources that you would expect in a UK hospital, the Tribhuvan University Teaching Hospital (TUTH) is broadly similar to a large district general hospital in the UK. I spent most of my time in the hospital in the Emergency Department (ED).

The staff in the department were welcoming to myself and others on elective placements and were willing to engage us in teaching and discussion of clinical cases alongside local students and trainees. We also joined in with the weekly departmental meetings. Many of the senior staff are forward-thinking and keen to implement improvements and new systems of work in the ED – that’s no mean feat when faced with a significant lack of resources.

TUTH is the largest government hospital in Nepal, but despite the funding, the treatment is not entirely free at the point of care. Whilst in the ED I saw numerous cases where family members had to buy blankets, pillows, thermometers, dressings, pain relief, antibiotics, and even blood for blood transfusions for the patient, which is obviously a massive contrast to what we are used to within the NHS in the UK.

Fortunately, in the ED and on some of the inpatient wards there are donation boxes where anyone can make a monetary donation, which is then given to patients who would otherwise not be able to afford the medications or resources they need.

The ED at TUTH is divided into green, yellow and red zones based on the level of severity the patient has been assessed as at triage. I spent most of my time in the red zone with the most unwell patients. Some cases I saw were similar to in the UK, for example heart attacks or acute lung disease, but there were other cases which I had never seen before (and would hopefully be unlikely to see again) including a lady who had a punctured lung from being run down by an ox, as well as severe machinery injuries that health and safety regulation would prevent in the UK. There were also cases of organophosphate poisoning – this pesticide is one of the most common forms of self-poisoning in the developing world due to its wide availability; it causes symptoms similar to nerve gas exposure.

The hygiene and sanitation facilities were also different to what I’d been used to in the NHS. Although facilities were available on some of the inpatient wards, there were no designated sinks for handwashing in the Emergency Department, and there were limited toilet facilities for both staff and patients.

Another contrast to the UK was regarding tuberculosis (TB). In the UK, patients with TB are isolated from other patients to prevent the spread of the infection. Despite the high numbers of patients with confirmed TB in the department, there were no side rooms or facilities to do this. Interestingly, the access to imaging such as XRay, CT and MRI scans was much faster than in the UK. Even non-urgent scans are completed and have results available within 24hrs – this usually takes weeks if not longer in the NHS.

Patients sent for a scan from the ED would usually be back within 30 minutes, with printed copies of their images in a folder attached to the bed, ready for the ED doctors to look at. Having hard copies to pass around meant that the team could assess the scans quickly, without having to log on and load the images on a computer like we do in the UK.

Rather than being filed in notes, patients keep hold of these scan images and bring them with them if they have to return to hospital. Despite the differences, it was clear that the core of this Kathmandu ED was the same as back at home – hardworking staff in a high-pressure environment, coping with difficult situations, aiming for the best outcomes for the patient even in the face of challenges.

Village Healthcare Experience

Most of Nepal’s population live rurally, approximately 25 out of the 30 million. Infrastructural challenges from the difficult terrain and weather mean that some villages are only accessible by foot unless it is dry – the narrow dirt roads cut into the valley sides are too dangerous for vehicles after heavy rainfall (Nepal has a monsoon season from roughly June to August). This, combined with a lack of qualified doctors even in the small towns, makes healthcare much more difficult to access than we are used to here in the UK.

Health outposts exist in some villages to serve rural areas without easy access to the towns – it is one of these where my colleagues and I were based for our rural healthcare placement. There are not usually full-time doctors at these posts, but there may be nurses or other staff who have some medical training.

‘Work the World’ organised the village placement for us, and we were led by guide and translator, Samir, who has some medical training and frequently works at the health post, meaning that he could explain to us how everything worked, translate medical terms and introduce us to everyone there.

Our journey out to the village consisted of 4-hours on a public bus from Kathmandu, after which we were fortunate to be able to get a ride on the back of a small flatbed pickup which was heading up to the village with some sacks of rice and a couple of other passengers. My heart was in my mouth every time we rounded a bend; the sheer drops off the side of the road were eye watering, and a few corners were so sharp the truck had to do a 3-point turn style manoeuvre to get around. We made it to the village in one piece and in much better time than the 4-hour hike we had been prepared to make.

During the rural week we stayed in the home of our lovely host, Ama. ‘Ama’ means ‘mother’ in Nepali, and it is used as a form of address much more often than using someone’s given name. Ama has adult children who work in Kathmandu so lives alone but with extended family nearby. She was an incredibly hardworking lady. We would get up around 5.30-6am having been woken up by the roosters, and she would have already fed and watered all the animals, done washing and chores, and have mugs of hot chai ready for us to drink as we sat sleepily in the porch. She spoke no English and my Nepali was extremely limited, but Samir would translate and help us all chat over dinner.

The main food in Nepalis is daal bhat – a dish of rice and lentils, usually with some sort of vegetable too. Rather than 3 meals a day, it is normal to only have 2, the first usually around 9.30am, and then an evening meal between 6 and 7pm. Daal bhat is served for both meals, which felt like a strange breakfast initially but turned out to provide us all with enough energy for the day’s activities at the health post.

The health post was very well stocked with medical supplies given its remote location. The storeroom was full and had a lot of the categories of medication you would expect in a UK pharmacy, such as antibiotics, painkillers, tablets for heartburn, as well as contraceptive pills. A recent addition was a portable ultrasound doppler machine, which can be used during pregnancy to listen to the baby’s heartbeat.

They also had a childhood vaccine programme and we met a number of young children coming in for their scheduled vaccinations in the week we were there. We saw a variety of cases during our time at the health post. Many complaints were similar to those in primary care in the UK – headaches, coughs, colds, minor injuries, rashes, etc.

One of the highlights of the week was getting called out to a home birth with the health centre nurse. After a short hike, we arrived at the house and met our patient. Her family were unsure whether to arrange for a jeep to take her down to the town in the valley, but this would take a number of hours at least, and after assessing her we explained that given how far into her labour she was, trying to move her would run a very high risk of her delivering while in the back of the truck. As part of the assessment we used the new ultrasound machine which we had taken with us, which reassured us that the baby was doing okay.

We moved our patient inside (she had been in an outbuilding when we arrived) and fortunately, the baby was delivered safely within an hour or so. It was a humbling experience to be a part of, but also eye-opening that had her family member not contacted the health post when they did, this first-time mum and her baby would have had no medical care.

The maternal mortality rate in Nepal has improved massively over the last few decades, falling from 900 per 100,000 births in 1990, to around 250 in 2015, although for comparison the figure in the UK is currently 9. The World Health Organisation has a global target of below 70 as part of their Sustainable Development goals, and so hopefully the figures in Nepal continue their trajectory to meet this soon.

Leaving the village gave me mixed emotions – on the one hand I was desperate to have a hot shower and eat something that wasn’t rice or lentils, but I knew the sense of tranquillity that we had found there would be shattered by the cacophony of car horns, bike engines and barking dogs as soon as we got back to Kathmandu. Winding down through the cloud layer we soon made it to the bus back to the city, but the village experience was truly unforgettable and is something I’ll carry with me both professionally as well as on a personal level. I’m so glad I had the opportunity to go.

Arriving in Nepal

I had read that I should be prepared for an assault on all senses when I arrived in Kathmandu, and so during our flight I had been mentally preparing myself for a long wait in the visa queue and an even longer wait at baggage reclaim.

This did not happen, however. Mother Nature intervened, and our flight became caught in a severe storm that hit Nepal and parts of Northern India. Lightning flashing at each window every few seconds, we circled for well over an hour waiting to be given the all clear to land. We later found out that most other flights had been diverted, which explained the eerily quiet ghost-town of arrivals that had been hailed as a usually chaotic riot.

Our first day in Nepal was our ‘City Orientation’. Once we’d changed our money and bought local SIM cards, we made our way through the hustle and bustle of Kathmandu. The unrelenting sounds of car horns, motorbike engines, barking dogs and the chatter from the throngs of pedestrians as we made our way through the city was discombobulating, and combined with the heat of the sun and eye-watering amounts of dust kicked up from the roads, the tranquillity of our destination, ‘The Garden of Dreams’ was exactly the interlude we needed. The gardens were a true oasis in the middle of the city.

Leaving the gardens, we headed to Thamel, the main tourist area. We stopped for lunch on the beautiful (and pedestrianised) Mandala Street. Lunch was in a bright and modern restaurant which served momos - a type of small dumpling that can be served fried, steamed or boiled, and are typically filled with either vegetables, chicken or ‘buff’, which we discovered was the main beef alternative, buffalo meat. Beef is not usually available even in tourist areas, as the cow is a sacred animal, and killing one in Nepal carries a hefty 12-year jail sentence. Momos tend to be served either steamed or pan fried, and are available in most restaurants as well as being street food.

Refuelled, we headed out of Thamel and took cycle rickshaws towards Old Town. We visited the temple of Seto Machindranath at Jana Bahal, a Newar buddhist monument that sits hidden from the road; this intricately detailed golden pagoda style building has been there since the 10th century.

Browsing shops along the way, we then headed to ‘New Road’, one of the more recently built areas of the city. More western style shops appeared, with many stores selling beautiful but expensive gold jewellery. The streets were packed with local people heading home from work, but we soon managed to find a taxi, and as we arrived back into our quiet suburb, we were exhausted but buzzing from our first taste of Kathmandu.