Introducing the Pediatrics Team

I thought you might enjoy meeting some of the doctors I work with.

Laxman (pictured on right below) is a general practice resident and junior staff doctor. He completed his medical school and internship in Nepal, then went to the U.S. to try to get into an internal medicine (adult medicine) residency program there. He had to take several very expensive exams, pay for his room and board, and work as a volunteer in a hospital before he could even apply. Unfortunately, the competition was pretty stiff, and he wasn't able to find a residency position in the US. Now he is trying to decide what to do next. There are a limited number of residency spots in Nepal, but it is very competitive – 20 to 30 spots for 2,000 to 3,000 applicants in internal medicine. So for the moment, he is working as a general practice doctor here at Tansen.

On the left is Kundan, so far my favorite Nepali intern. I have really enjoyed working with him – he is always happy, humble and willing to let me see patients and figure out how to manage them. He loves soccer and recently was injured during a hospital soccer game. The interns and residents play every day on the "tennis court," an enclosed cement (yes - cement for soccer...) surface. Poor Kundan hit the goal post, broke a couple of front teeth and bruised his lip and face. He made the goal, though! Unfortunately for me, Kundan is rotating to labor and delivery this week. I will miss him!

SIDE BAR: In Nepal (as in many other countries), students go to medical school right after high school and study for five years. The last year is an intern year, where they rotate through various departments and are responsible for patient care under the supervision of a higher level doctor. Unlike in the U.S., once they finish their intern year, they are able to practice medicine as general practitioners. Residency, or specialization (e.g., pediatrics, adult medicine, surgery), is optional, and though many desire to specialize, the opportunities are limited. Nepal has very few residency programs, so competition for spots is fierce. Those with financial resources can apply for residencies in other countries (India, U.S., etc.), but they must take a series of expensive exams and compete with other national and international candidates for residency spots. In many cases, foreign residents are not paid, making it even more difficult for those of limited means to specialize. Imagine working 80+ hours as a resident and not getting paid! In the U.S., at least we get paid as residents, however minimal the salary. One of the sad results of this system is the “brain drain” from poor countries like Nepal. The absence of specialty training and lack of opportunities for financially and personally rewarding practice causes many doctors to look for work outside Nepal. So I especially appreciate physicians like Rachel and her husband, Dipak, for their commitment to serve and work in areas where most Nepali doctors would rather not live.

Dr. Rachel (everyone uses their first names here), pictured with me above, is from India and completed medical school and pediatric residency there. She and her husband Dipak (an orthopedic surgeon) are Christians and have contracted to work at Tansen Hospital for a number of years. Dipak is from Nepal, but studied in India (where I assume he met Rachel). They have one daughter and are expecting another baby. Rachel speaks several languages, including English, Hindi and Nepali, which she taught herself upon arrival at Tansen. I really enjoy working with her; she is loves to teach, has a great sense of humor, and is warm and compassionate with patients. I hope to get to know her and her husband better over the next few weeks.

Pictured here from left to right are Laxman, Dalaki and Ashok. Ashok is another Nepali intern who attended medical school in the Phillipines and only started his intern year a month ago. He is very nice to work with also. Dalaki just started on pediatrics today, so I do not know her story very well. I look forward to getting to know her.

By the way, this photo was shot in the hospital canteen, where we all head after morning rounds for "chiyaa" (tea) and snacks (samosas and other sumptious treats). I eat lunch here most days. It's fun to go into the kitchen and point at things and say, "yo ke ho?" (what is this?). Everything I've tried so far has been mitho (delicious).

Just for kicks, here's a photo of another patient we saw in outpatient clinic who complained of fever and lymph node swelling. Can you see the big knot in his armpit? Definitely not normal. We sent him for a biopsy. Oh, and the little girl we thought had rheumatic heart disease actually turned out to have a congenital heart defect. She had a hole between the two atrium (smaller chambers of the heart), as well as a hole between the two ventricles (bigger chambers of the heart), causing blood to recirculate from the left side of the heart to the right side. This makes the pump much more inefficient, since much of what is supposed to go out to the body goes back to the lungs. The good news is that she now qualifies for a special Christian fund for congenital heart surgery, which would not have been the case if her heart were damaged from rheumatic fever. I got to watch Dr. Sunil do the ultrasound of her heart and see the reverse blood flow and holes in the heart walls - pretty cool!

This week, I witnessed my first pediatric death. A little boy was brought in with uncontrollable seizures. He had had a brain injury at birth from lack of oxygen, and the damaged areas of his brain caused him to have seizures from a very young age. Generally, his seizures were controlled with medications, but he had been hospitalized many times when the medications stopped working and had to be tweaked. This time, though, nothing seemed to help. He remained in a state of seizure for 30 hours!! Obviously, that wasn't good for his body or his brain. During seizures, the muscles, brain and other organs are deprived of oxygen. So had he survived, he would likely have had a very poor prognosis. Although he did eventually stop seizing, he never woke up. Finally, his poor body just gave out. The parents seemed to understand that the hospital staff and doctors did everything they could to keep him comfortable, and I hope their compassion and dedication were a powerful witness to the family and villagers of Christ's love. Again, please keep all of these folks in your prayers - and me as well.

Nepali Church

Nepali Church

Saturday is the day of worship here in Nepal – for Hindus and Christians apparently. So rather than take a 20-km hike this past weekend, I decided to go to church – only a 15-minute walk. Needless to say, I made it there and back without too much pain. Actually, despite the fact that I didn’t understand a word of the service, I truly enjoyed it.

There are, in fact, some six or seven churches in Tansen according to my sources. Most of the missionary doctors go to one of two churches – the Upper and Lower Churches (referring to geography, not status or liturgical style). I went to the Upper Church this Sunday for several reasons: (1) I knew where it was (more or less); (2) I didn’t have to walk uphill coming or going; and (3) the tailor who is making some Nepali clothes for me and his wife attend the Upper Church.

Worshiping in a foreign country, culture and language is always a moving experience for me. I find myself overcome with joy and excitement to see that God indeed has chosen people from every nation, tribe and tongue to be part of his family. And he has effectively called them and saved them through the same Gospel that saves people like me. Even in a place as remote as Tansen, Nepal, where Hinduism and Buddhism have reigned for centuries, God has shone his light in the hearts of a few familes to give the light of the knowledge of the glory of God in the face of Jesus Christ. Imagine worshiping to familiar music with words that are entirely unknown, but knowing that they point to the same glorious, eternal truths that we sing about each Sunday. For me, it’s a small foretaste of heaven.

Talking to Nepali Christians, I understand that converting to Christianity, while no longer illegal in Nepal, can lead to persecution. One family I talked to stated that when they became Christians, their parents and siblings essentially disowned them. They can no longer participate in Hindu ceremonies, which make up a huge part of family culture, interaction and relationships. Thus, those who convert are often shunned as ungrateful, disloyal and negligent. Some Christian shop-keepers lose business because their Hindu customers no longer buy from them. I am definitely humbled by the faith and courage of these brothers and sisters and reminded that there is a cost to follow Christ. Just as he laid down his life for us, we are called to give up our lives for him. That idea has taken on new meaning in the present context.

Clinical Work in Tansen

Now on day three of my pediatrics rotation at Tansen Hospital, I am getting the hang of how things work on the wards and in clinics. Each morning at 7:45 AM the medical staff meets for devotional time - Bible reading and prayer - followed by presentation of the cases admitted overnight on the different services. Then we round on the inpatients. At any given time, there are around 30-40 patients on the pediatric ward, not including the newborns on the maternity unit or the orthopedic and surgery cases. We see each patient every day, which usually takes until 10:30 or 11:00. Then we have tea (chiyaa) before heading to outpatient clinic, where there are some 70-80 patients to be seen each day. "We" consists of two interns, a general practice resident and the attending. Since I don't speak Nepali, I don't get to do much on my own, mainly observe. But I do ask lots of questions, and I get to examine each patient, so I am learning a lot.

On the inpatient service (kids in the hospital), we have many cases of typhoid fever and meningitis, as well as pneumonia and neonatal sepsis (newborns, especially preemies, with widespread infection). But we also have some unusual cases, such as this little 5-year-old boy, who was admitted with heart failure due to severe anemia. His hemoglobin was about 3 (normal is over 12!!). With such a low hemoglobin, his poor heart had to pump overtime to get enough oxygen to his body, and it just couldn't keep up. He is doing much better now after three transfusions, but he probably has some kind of congenital problem that will require blood transfusions for the rest of his life. We suspect thalassemia (a genetic defect in the production of hemoglobin molecules), but he will have to go to Kathmandu for the special tests to diagnose the problem. The mission hospital here in Tansen has agreed to help with the family's travel costs to Kathmandu, as well as the costs of long-term follow-up in clinic, lab tests, and ongoing blood transfusions.

Another interesting case is this 6-year-old girl with rheumatic heart disease, who also came in with heart failure and a huge murmur caused by diseased heart valves. Rheumatic fever is a complication of strep throat infections. It is relatively uncommon now in the U.S. because most strep throat infections are easily treated with penicillin. But here in Nepal, many families don't have easy access to health services (i.e., they have to walk for hours or days to the nearest hospital), so there is a much higher incidence of rheumatic fever. One of the most serious complications of rheumatic fever is damage to the valves of the heart, causing leaking of blood back across the valves when the heart pumps, instead of forward to the body. This can lead to back up of the whole circulatory system, with fluid in the lungs, congestion of the liver, and swelling of the extremities and abdomen - which is how this patient presented. She is doing better with treatment of her heart failure. An ultrasound of the heart will help us to see how much damage there is to her heart valves. She may eventually be able to get heart surgery in Kathmandu.

Unfortunately, not every story has a happy ending. Last night, one of our newborns died from overwhelming infection. He was delivered at home and developed an infection in the first few weeks of life. By the time he reached the hospital, he had to be intubated and placed on a breathing machine. Despite antibiotics and all the right care, he didn't make it. Yesterday, I attended a c-section of a woman with twins at 33 weeks of gestation. One of the twins was discovered to have died in utero due to a complication known as twin-twin transfusion (where one twin "steals" the blood supply from the other), so the poor mother had to undergo surgery to deliver one deceased baby and one premature baby. The living twin, weighing 1.5 kg (about 3.5 lbs) is doing well as of the time of posting this blog.

Please pray for these patients and their families. It is devastating to lose a child or to be told your child may never be normal and healthy. Most of the families are very poor, so the burden of caring for a sick child is enormous - not just hospital costs and medications, but travel costs and time lost from work to bring the child to town. I wish I could pray for these families in their own language. But at least I want to offer to pray for them in English if I can find someone to translate my request. So please pray that I will be able to demonstrate the love of God to them before they are discharged.

Walk to Ranighat

On my second day in Tansen, I decided to join my fellow medical students for a hike to one of the local attractions. Ranighat is the site of an old palace built in 1896 by Khadga Shamsher Rana, an exiled politician who aspired to take over leadership of Nepal but never quite made it. Known as the Taj Mahal of Nepal, Ranighat has long been stripped of its contents but stands majestically on a bend in the Kali Gandaki River. (See photo album below.)

Walk to Ranighat

The walk from Tansen to Ranighat is about 20 km round trip. (Yep, that's right!) And about 1/3 to 1/2 of the way is uphill. Had I know this at the outset, I'm not sure I would have tried it. But I wanted to do some hiking, see some sites, and bond with my fellow medical students. (Maybe a little pride in the decision?) All I can say is that I think I pushed my leg muscles beyond their capability. I wanted to cry at the end when I had to stop every 10 steps for rest and around every bend saw the road keep ascending at a pretty steep rate. (Actually, I think I did cry once.) It was really hard, and I am still limping and sore. But I guess you could say it was worth it. I am very thankful for all the helpful people we encountered along the way who guided us to the correct paths. I've now heard several stories of hikers getting lost and walking for several extra hours!!

Arrival in Tansen

After three days in Kathmandu, I have finally arrived in Tansen, where I will spend the next two months working at the Tansen Mission Hospital. The trip from Kathmandu was made in the Tansen Hospital bus or "Buck" (so named because it serves as bus for passengers and truck for supplies), which makes a weekly roundtrip journey between Kathmandu and Tansen. The entire trip took approximately 10 hours, including one stop for repairs and several stops to negotiate our way through roadblocks.

Shortly after starting out, we received a phone call from the medical director of Tansen Hospital informing us of reports of blockades along the main Nepali highway. Demonstrations of political and economic discontent continue to plague the country, especially in rural areas. Our bus driver was not at all daunted by the prospect of blockades. Fortunately, he was quite good at talking our way through these obstacles by insisting that we were carrying important supplies that had to make it to the hospital that day. In fact, we were carrying rabies vaccine for a boy in Tansen who had been bitten by a rabid dog. So in the end, the roadblocks didn't slow us up at all.

However, we did stop for an hour or so to make repair to the bus. This gave me a chance to talk to one of our Nepali passengers, Sumi, a young Hindu woman who lives in Tansen but is studying health education in Kathmandu. She taught me some Nepali phrases (What is your name? My name is Pam...) and shared her Ramen noodles with me. She lives close to the hospital, so hopefully I will see her often.

Travel to Tansen

The rest of the trip was uneventful, save for the oppressive heat during the middle portion of the trip. The road took us through some of the lower areas of Nepal near the Indian border. Closer to Tansen, the terrain is more mountainous with stunning views of lush hillsides, terraced rice paddies, and Monsoon-swollen rivers (see photo album). The best treat of all was to get a glimpse of Himalayan peaks rising out of the clouds behind Tansen's green hills. What a glorious welcome!

Bicycling to Bhaktapur

On my second full day in Nepal, I had a bicycling adventure with my fellow medical student, Alice and her husband Ben from New Zealand. Being young and adventuresome, they decided to rent bikes to ride out to a rural village called Bhaktapur. And, not wanting to be a stick in the mud, I decided to join them. We rented bikes for the day for 150 rupees (about $2) - not the best equipment in the world, but hearty enough to stand the Nepali roads. My bike didn't change gears at all. Fortunately, it was stuck in the easiest gear! Even so, I couldn't make it up all the hills with the 99-degree, 99% humidity weather. Traffic was crazy until we got a bit out of the city. Even so, it was interesting weaving in and out of cars, trucks, buses, pedestrians and motorcycles. I prayed a lot, and we made it to Bhaktapur and back (at least 12 km each way) safely.

Bhaktapur

Bhaktapur is an old city with 170 temples! It looks like a medieval city even now with dark, narrow streets and people drying chile peppers in the squares. Actually, I found it really dark and oppressive, but fascinating. The streets and squares were lined with hundreds of little shops selling religious items - paintings, incense bowls, figures of gods and Buddhas...

According to my contacts in Kathmandu, Nepal is approximately 80% Hindu with a significant Buddhist segment as well. Tibetans fleeing China in the 1950s moved to Nepal and established many temples and monasteries. Nepal is also home to the supposed birthplace of Buddha, Lumbini, a town located close to where I will be for the next few months.

First day in Nepal

Arrived safely in Kathmandu after a 30-hour trip via Amsterdam and Delhi. Travel went smoothly for the most part. I did't get much sleep on the trip because I ended up watching three movies - Star Trek (twice actually), Marley and Me and Taken. In Delhi I had to transfer airlines. I was told they would bring my bags for me to identify and my boarding pass. So I spent the night in the transit lounge waiting for the Jet Air folks to come and reassure me I was on the flight to Kathmandu. They came 40 minutes prior to departure. But my bags and I arrived with no problem.

Kathmandu is charming - lots of old and new buildings, mostly 3 or 4 stories, with temples mixed in on every corner almost. Traffice is typical of a third world country. People walking, bikes motorcycles and cars all trying to get through very narrow streets. No traffic lights of course. Add to that the fact that they drive on the left here. So crossing the street is quite an experience - I have to remember to look the right direction and try to weave my way through oncoming vehicles who don't stop and give no indication if they will go around you or not.

Kathmandu

Last night I met a group of New Zealanders here on a mission trip. They invited me to join them for dinner, which is good since I wasn't keen on trying to find a place on my own. I had "mo-mo" - sort of like Chinese dumplings, with a curry sauce. Yum.

I am staying at a Christian guest house close to a commercial center with lots of shops. Actually I am sitting at a Christian coffee house called Higher Ground with free wireless connection overlooking the main street in the neighborhood. Just finished a cappucino and banana smoothie for breakfast.

This morning I met Alice and Ben from New Zealand. Alice is in her final year of medical school and they will be going to Tansen with me. We walked around the neighborhood and found our way to Durbar Square, where there a number of Hindu and Buddhist temples and a palace. Quite interesting. Well, all for now.