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Elective report - Dr Jamie Goodhart

Medicine in Manthali – Elective Stories from Nepal

Dr Jamie Goodhart / FY1 Doctor / Edinburgh

In 2011, Jamie rashly gave up a well-paid career in Telecoms, opting instead for the delights of Warwick Medical School. Now a Foundation Doctor in Edinburgh, Jamie is also a mountaineer, drawn to the high and untouched regions on the world. During his time at medical school he founded the Warwick Wilderness Medicine Society and became involved in altitude research. While undertaking his medical elective in Nepal, he read the late Dr Oliver Sacks’ ‘Awakenings’, a tale of extended case histories that had grated with the medical establishment upon its publication in 1973 on the grounds of being ‘not scientific’ enough. He found the humanisation of patients in these stories inspirational, and has written of a number of encounters he had in Nepal with this in mind, as a set of reflections and stories.

hospital

Tamakoshi Hospital

The backdrop is Tamakoshi Co-operative Hospital in Manthali, 8 hours’ bus journey from Kathmandu. The hospital was composed of 2 doctors, 3 medical assistants,10 nurses and midwives, 2 opticians, a dental assistant, an X-ray machine, an ultrasound machine, a tiny lab, an emergency room, a bed for minor procedures, dental and opticians’ facilities and a whole floor for surgery camps. There were 5-10 inpatients at any one time, relatives everywhere and the medics saw up to 90 outpatients daily with a least this number again visiting the other departments.

It Is Not Your Decision To Die

A nurse in a white flowing sari pushed past the people clustered outside the outpatient department and hailed Tara, in Nepali. Tara was the most experienced Medical Assistant at Tamakoshi hospital. He jumped up and followed her out. I had learnt that this procedure indicated that there was something going on, so followed. We processed 20m along a balcony lined with patients to the emergency room, arriving to see a semi-conscious 80-year-old lying on a green stained bed by the window. He was surrounded by nurses and, peripherally, by an entourage of slightly younger old men who were perched on stools, tables or whatever they could find. All were wearing the traditional Nepali multi-coloured topi (hats) and waistcoats.

The history from the family was vague, but we established the gentleman had been unresponsive for a time on the previous day also. After an A-E approach and administration of oxygen his GCS was 8. His first bloods came back with a haemoglobin of 4, and the contention was that anaemia of unknown origin was the primary cause of his presentation. There is no blood available in Manthali for transfusion.

I walked into the ward a couple of hours later and the anaemic octogenarian was sitting up, alert, and talking at great speed with his family. He didn’t exactly look spritely, but he didn’t look too sick either. The ward-round commenced shortly after and having checked out the breast abscess, abdominal pains, COPDs, pneumonia and babies with fever, we came back to our pale patient. We were none-the-wiser as to the cause of his anaemia and the lead doctor began to take a history. The atmosphere become tenser and the old man raised his voice, followed by the doctor. This escalated into what seemed to be a row, with the family chipping in on the doctor’s side. Sadly I didn’t really know what was going on; it was all in Nepali, in which my understanding is limited to pleasantries and a motley collection of medical words. The drama continued for a couple of minutes, then stopped as the ward round dissipated.

Later, when I asked the doctor what it was all about, I was told that the gentleman had said that he wanted to die. That his parents were dead, his brothers were dead, his sisters were dead, some of his children were dead and he didn’t want to live anymore. This had prompted the argument and the doctor’s response, “It is not your decision to die”. He gave a little laugh and smile as he told me. He continued, “I told him, it is not in our religion to choose to die. Your children don’t want you to die, I don’t want you to die and it’s not in our culture for you to decide to die”. There followed another little laugh. “I told him these things”.

Like many of our patients, the gentleman discharged himself home, probably to die. Afterwards, I mused on the situation, and decided that in the context I was working, the old man’s decision seemed to me a reasonable one. The difference from that to which I was used in the UK was the doctor’s overtly paternalistic style, and not the patient’s autonomous decision.

Too Much Black

Every morning the x-ray machine at Tamakoshi was in almost constant use. Chests, arms, legs, hands, shoulders and a suspicious number of abdomens were x-rayed. This led to a constant stream of, all to often, low quality x-rays to interpret. Herein lay a problem. There was no radiologist, nor anyone nearly a radiologist at Tamakoshi. The two doctors who worked there were far removed from being so: it had been decades since they attended medical school, and they had rarely received teaching on, or confirmation of their interpretation of, x-rays or diagnoses. Everything was fine when there was a clear break of a bone or obviously pathology, but in the absence of this the doctors blustered knowingly, a technique which rubbed off on the medical assistants. There was of course nowhere to refer to for an opinion. In addition, the patients often requested an x-ray of a particular area because of a colloquial understanding that the x-ray in itself was curative. The doctors generally acquiesced. In summary, there were x-rays being done with and without a good indication, often of poor quality, and with occasional questionable interpretation.

The biggest problem area was chests. An x-ray is a 2D image of multiple overlapping 3D structures, often with subtle signs. Tricky to interpret at the best of times, certainly for me, and many chest x-rays were done each day at Tamakoshi. They were almost inevitably under-penetrated and rotated, and were habitually interpreted using a dirty window rather than the one semi-functioning light box. With so many variables, I found chest x-rays particularly difficult to interpret (excluding barn door diagnoses), so decided to educate myself. I used an inspirational radiology presentation I had seen while rotating through a respiratory firm to try and embed theory, a system, tricks and tips*.

Despite my study I wasn’t making much headway at Tamakoshi. I was hunting down the plates (it was the first time I had seen an X-ray on anything other than a computer screen), taking them to the light box, playing with the plug until the loose connection sorted itself out, and being religiously systematic. Often scratching my head and wishing there was someone to tell me the answer, if only to corroborate my understanding. After a week of this it came to me that in the medical context of rural Nepal, x-rays were mostly an adjunct to diagnosis, building into an overall clinical picture, and it was ok not to know the answer, a fact I concluded could also be true at home. Perhaps initially some of the locals’ faith in the magical power of x-rays had rubbed off on me.

In my last week in Nepal, however, I was on a ward round when a new chest x-ray was delivered; about 10 people waved it around by the window for a minute, deciding pneumonia. A bit later I sought the plate and took it to the light box for a go at systematics. The bases looked a bit crowded, perhaps consolidated, particularly on the left. Going through my system there was definitely ‘too much black’ at the left apex extending down to about the 3rd rib. It was asymmetrical and there were no lung markings. A pneumothorax had been missed and was compressing the rest of the lung, increasing the lung markings on the left.

lightbox

Finding the pneumothorax was one of the first times that as a medical student I have been able to contribute anything meaningfully to care (a big problem in UK training), and was incredibly satisfying in its own little way.

Tea With An Itchy Lama

Mid way through my elective I unexpectedly and happily got the chance to work for a week in a health post in the town of Bamti. This was two days’ trek along the route to Everest base camp as walked by the successful British expedition in 1953. Nowadays this route gets relatively few visitors as most people fly into Lulkla, a week or so closer to Everest on foot. The health post’s hours were just 10am-2pm, which left the afternoons and evenings free for me to explore. I mainly climbed the surrounding hills, for the fun, the views and to help with acclimatisation for the trekking I was planning.

One day I climbed the 900 vertical metres from Bampti to Thodung Gompa (a Monastery), seated at 3000m. When I arrived it was quiet, with just four child monks (lamas) and a very old-looking lady lama wearing an orange jumper. She had no hair, an outdoor face with small eyes, a big smile and skin stretched tight over her cheeks as though she’d had a facelift some time in the distant past. I spent some time with these five, exchanging the usual pleasantries of those who don’t speak each other’s language. Namely, “Namaste” and “What is your name?”. The monastery’s Gompa was then unlocked and I was given a little tour of the lavish inside, which I photographed with great relish.

gumpa

After my camera was replete, our little band was chilling out on the steps when the head lama at Thodung appeared. He was somewhere near forty and spoke a little English, learnt straight from a dictionary. He had lively eyes, a shaved head, and was incredibly friendly. Immediately on finding out that I was working at the health post he showed me his neck saying, “very itchy, very itchy”. I could see a raised lichenified skin lesion about 4 by 2 cm with a slightly smaller and less raised sister lesion beside it. He gave a two-year history of the problems, said he had tried creams from the health post without success, and asked could I help? I remember mumbling something noncommittal. We went to the monastery’s smoky kitchen and I drank prodigious amounts of sweet tea from a small china bowl that was refilled by a 10-year-old lama each time I got to its shallow bottom. I was told about a really important ‘Big Lama’, who was visiting later that week. It soon got late and I made my excuses, but promised to return to meet the Big Lama and to bring some medication for the skin problem, though I could not guarantee it would work.

I really didn’t know what to do for the lesion. Dermatology is not my strong point, particularly when various creams hadn’t worked. I needed help. Bamti doesn’t have a great deal of internet access, but there was a charity school nearby which had a connection to allow the orphaned children to communicate with their sponsors. I asked to use it and sent a photo of the lama’s neck to Tamakoshi hospital for advice. They had a look and diagnosed chronic tinea, and suggested a month’s course of antifungal and steroid.

So three days later I found myself again climbing the 900m to Thodung, my bag filled with medication, with the bonus of seeing the Big Lama (who was important enough to arrive by helicopter!). The itchy lama seemed pleasantly surprised to see me. I got the impression he didn’t think I would return. He was even more surprised with my presents of cream and pills; he was all smiles and blessed me.

The Many Things

I have many more medical and other stories to tell, if time and space allowed. There was the patient with status epilepticus caused by cysticercosis, nasty trauma, and the chants and throwing of rice by a traditional healer. I saw severe harm caused by excessive use of NSAIDs without gastric protection, put together a diabetes management card and worked at a remote Health Camp where we saw 350 patients in 4 hours. I spent much of my time inside a traditional clinical environment, but also saw a large amount of Ayurvedic and homeopathic medicine being practiced. In 5 weeks, I saw more fractures than I had seen in my orthopaedics and A&E rotations combined, and more patients than when on rotation in general practice. Last but not least, I spent 5 days trekking solo in the Himalayas, sleeping out in the open at 4000m, watching the snows billowing off Everest.

I did over 100 patient consultations whilst in Bamti and learnt a huge amount about low resource medicine and deep reflection. However no ‘consultation’ was more satisfying than that with the lama up the mountain, not least because of all the smiles and happiness than my medicine brought. It is difficult to put my finger on exactly why, but the combination of not knowing the diagnosis, using telemedicine, climbing almost 2000m and generally having to work hard made it very gratifying. Of course being blessed by a lama has got to be good for my Karma too…

Further Information

Where / Tamakoshi Co-operative Hospital, Manthali, Nepal. It regularly hosts volunteer doctors, nurses, midwives and dentists as well as medical students. It is an extremely welcoming, friendly place.

Accommodation / The hospital provides basic food and board in a block perched on the hill above the hospital. For this they ask in the region of £100/month.

Contacts / Elective & hospital placements are organised through Rural Assistance Nepal. The lead clinicial at the hospital is the dynamic Dr Suman, who is an inspiration, and the Tamakoshi Co-operative Hospital website has more information on the hospital itself.

*Thanks to Dr Natasha Jefferson, a radiologist at Warwick Hospital, for emailing me the chest x-ray presentation. It remains the best radiology teaching I have ever had!