Heather Ferrari
Heather Ferrari
Nepal 2018
Namaste! I am a recent nursing graduate interested in community healthcare. While traveling to Nepal for 14 weeks my hope to learn more about the Nepalese culture, Nepalese health disparities, and the treatment of health care in a developing country. As well as establishing life long friendships, join me and follow along on my journey. Read More About Heather →

tata (good bye in Nepali)

Well my last two weeks in Nepal have come to an end. As I head off back to America. I have tried and tried to reflect on my time the final two weeks I have been here but I am still at a loss for words for my time here in Nepal, hopefully once I return to the states and take time to rest and reflect in my time here I will be able to form words for my experience here. One word that comes to mind right now is grateful.

So last week I spent time in the Ortho unit. Most of the patients I saw were bandaged. I do not know much about orthopedic patients, and trying to ask and be told things by Nepali nurses and doctors can be a little difficult to understand, they do not always use the same words we use to describe things. Many of the patients had Ilizarov Apparatus which is a external fixation type of cast, and is used to treat compound or open bone fractures. The first day on this floor a nurse came up to me and asked if I could take manual blood pressures, I said yes, and so the two of us went around to all 30 patients on the floor and I recorded their manual blood pressures. Some of the patients would speak English and some of the patients, especially those with high blood pressure knew their blood pressure numbers exactly, even before I told the nurse. There were two patients who were both patients brought into the ER when we worked our night shift, who then had surgery and were transferred to the post-op floor, which then I was able to continue following the patient’s care. They also used traction a lot with jugs of water. There are no hard casts in Nepal, how they cast an injury is by taking what looks like a metal ladder and wrap thick gauze all around it and they use that to stabilize the broken limb and then they wrap the limb and brace with something similar to an ace bandage. 

The other half of the week went spent doing out reach programs. One day we went and toured the local hospital and the cancer hospital to see the differences compared to the private hospital we have been volunteering at. The local hospital was very chaotic, and much older then the private hospital. The cancer hospital in Chitwan use to be the biggest cancer hospital in the country. We were not allowed to look at patent files or participate in any care at either of these two places but I enjoyed seeing how they differed from the private hospital. Another day we went to ABBS which a daycare that treats physically or mentally disabled children. We were about to watch the physical therapist come in and work with the children who had physical disabilities, because it was festival time there were not many kids. The last day of outreach we went to a local school and taught hand hygiene and oral hygiene to third graders. The third graders thought we were the greatest people ever and they were really smart and could answer all the questions we asked. They understood the importance of brushing their teeth, but we had to clarify some things about hand hygiene as Nepali people eat with their right hand and wipe with their left. 

The final week I spent my last few days in the CCU before heading off the Kathmandu to explore. The most fascinating patient was an older women who had already had a valve replacement as well as a PCI, but she was still having problems. The first day I saw her she was on a temporary pacemaker, and the doctors were discussing whether or not the family could afford a permanent pacemaker. The family decided that she would receive a permanent pacemaker, and sadly I was not able to go see the placement of the pacemaker. The next day I came on the unit she had her pacemaker and they were beginning to prep her for discharge. My last day I spent time in the ER which was exciting but also emotionally draining. We had three very critical patients come in. The first patient came in after collapsing on his morning walk with right side weakness and facial drooping. After almost two hours of him sitting in the ER waiting for his family to pay for all the treatment he went to CT and they discovered he had a hemorrhagic stroke. The next two patients that came in were brothers. They had both been electrocuted and the older of the two brothers was already gone when they wheeled him in and the other brother they were fighting to save. They started an IV, put him on oxygen, and he started desating so they intubated him and once he became stable enough they transferred him to the ICU. This scene just keeps replaying over and over in my head. I see the brothers being brought in, the dad being taken to see his now deceased son, while his other son is fighting to stay alive. The mom couldn’t handle it. She ended up laying down in a patient bed shaking. The whole time I had been in Nepal I had never seen 1) this many people in the ER 2) so many family and friends come visit 3) this many people cry, and not just cry but wail. Sadly, I witnessed some deaths while in Nepal, but none of those family members showed their emotions in public like the family members and friends of these two brothers. 

After quite the exciting week, I was headed off to Kathmandu to go exploring by myself around the city and the out lying towns. Traveling alone really teaches you a lot, and builds confidence in yourself that you can conquer anything. I will never forget my experience in Nepal, my second family, and all the great relationships I made. I am excited to share in person everything I have observed, experienced, and learned.

Skeletons in the ER

This week I spent my time in the Emergency Department. The most common incident would be a motor vehicle accident, and the second most common was physical assault.

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Here are some patients I saw through out the week in the ER:

  • Motor Vehicle Case: The patient had fallen off a motor vehicle and shattered every bone in his face. His whole face was swollen and black and blue. He could barely open his left eye and his right eye was completely swollen shut. They did a CT scan and an X-ray of his back, his brain had no damage and he had not damage to his spine, which is honestly amazing. He would receive surgery in the next few days. 

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  • Physical assault case: physical assault cases are very common especially during festival season. According to one of the doctors I spoke with, many people drink during the festival season especially men and they tend to get in fights and end up in the hospital. This patient was hit over the head multiple times with a plank of wood. The patient had two huge lacerations and two lacerations on his back. One of the doctors stitched the two lacerations on his head with very little stitching, there were areas that were still open. I would have thought they would have stapled it, but I guess they do not have the money to staple. It surprised how few sutures they did, what I would have thought required around 10 maybe more they used six. 

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  • Drugged Addiction: this patient came in after realizing his injection site in his lower thigh region started to have pus discharge. This patient had been injecting drugs for 20-25 days, and the discharge has been the most past 20days. It took a while for the nurses to get IV access, at least three of four tries
  • Cardiac patients: two cardiac patients came in around the same time. One patient was in hypertension crisis. The patient sat around for a while with no treatment taking place because the family had not paid yet, they were waiting in line to pay. Once the family paid the patient went for an angiogram and PCI. The patient had had a anterior wall MI about 4-5 hours ago. On his monitor you could clearly see ST elevation. The other patient was in SVT and transferred to the CCU, after being give amiodarone. 
  • On Wednesday I walked into the ER as a nurse was walking from the ambulance area through the ER to GYNO/OB carrying a baby. I went to the ambulance dock and saw that a mother had given birth to the baby in the ambulance. After a little while, I left the ER to go check on the mother and baby, the mother was being cleaned and stitched, and the baby was healthy sitting under a heating lamp. 
  • On Thursday there were two chronic alcohol patients: one patient had a seizure disorder from the alcohol. The other patient was having tremors, auditory hallucinations, and was tachycardic.

On Friday, two other volunteers and I worked night shift in the ER. The beginning of the night was quite busy. There were many patients with motor vehicle accident, a patient with appendicitis, a patient with gallstones, many patients in the observation ward, and some physical assaults. Around 10pm is when the night started to get busy. There were three motor vehicle cases and a very very drunk patient. The first motor vehicle case the patient was riding a bike and got hit by what is similar to our garbage trucks. His fibula, tibia, some ankle bones, and many foot bones were all broken. The patient was placed in a almost full leg cast and would hang out in he ER until surgery the next day or even the day after. Another motor vehicle case was a older patient who was intoxicated and got in an accident. He had a broken arm and was also placed in a cast until surgery the next day or even the following day. The drunk patient was very aggressive and almost fell out of her bed multiple times. Her family had to keep her in bed with all their strength to prevent her from falling out of bed. Her family also believed that she might have taken drugs as well. After around 2am it was very very slow until our shift was over. Working a night shift here really let me see what evenings are like in Chitwan. We don’t really leave the house after dark, so it was interesting riding to work in the dark and seeing how busy the streets were. 

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A normal routine for a patient. The patient will arrive via ambulance or walk into the ER. The patient will then be placed in a bed, and assessed. After the assessment is complete the family then takes the orders to the billing counter and the patient’s family pays for all the treatment that will occur, which could take anywhere from 10mins to over an hour depending on ow busy the ER is. The family then comes back with the statement saying they paid and the nurses and doctors begin treating the patients. If the patient needs stitches there is a procedure room where the patient will receive stitches, where yet again the family has to go out of the hospital to the pharmacy to get the sutures, and any other supplies that might be needed. The patient is then stitched up and moved back to the ER area. There is a yellow zone, a red zone, and an observation ward. The yellow zone is less critical than red, and the observation ward is after the patient becomes stable but still needs to be observed before discharge. Once the patient is stabilized he/she will be either transferred to a floor or moved to the observation ward, from the observation ward the patient may go see doctors in the out patient department if the patient is not critical enough to be admitted, but needs to see a specific doctor. If the patient does not need to see a specific doctor then the patient will be discharged from the observation ward. Most of the patients in the emergency room are not super critical and the critical ones get stabilized and transferred to an ICU floor. 

Observations made:

  • Alcohol addiction, drinking and driving, and motor vehicles are a problem
  • Motor vehicle accidents (bikes, motorbikes, and tuktuks) are common and road rules, stop signs, stop lights, or any traffic controls are nonexistent 
  • Many patients have back flow of blood into their IV lines, patients will randomly disconnect their IVs lines themselves even while medicine is running. 
  • Physical assaults are very common, often times I thought that accidents were occurring like running into something or something falling while working because there were so many physical assaults I didn’t think it was possible to have that many but nope people really get into fights here.
  • They don’t run toxicology reports for alcohol or to figure out what drugs patients took, they only have access to be able to test certain drugs, but it has to be with in a certain time of consumption. 
  • On night shift there are no surgeries except emergency surgeries which include gallbladder removal, appendix removal, or c-sections. Most night shift surgeries that occur are c-sections. 

 

 

Happy Dashain ❣️

Well I have been home for almost a week now from trekking. When we returned from our trekking in the Annapurna region, the following day the festival of Dashain started. This is one of the longest most celebrated Nepali festivals. It celebrates the triumph of good over evil. This holiday is very similar to our Christmas. Family comes into town, it lasts for 15 days, blessings occur with tika, and money and gifts are given. This week has been a very slow week in the hospital because many patients are sent home for the festival. We only worked three days this week, as the other two were spent celebrating the festival with our families.

I spent one of the days in the tropical medicine ward, which also is an endocrinology ward. Many patients in the tropical ward have the diagnosis of AUFI, acute unknown fever illness, diabetes, typhoid, dengue fever, scrub typhus, and malaria. Most of the patients I saw were positive for scrub typhus. Scrub typhus is a disease caused by bacteria that you get from a chigger, tick, or mite bite. It is often associated with thrombocytopenia, fever, and body aches. The patients receive doxycycline and are under observation for a few days until they can be released from the hospital. On our rounds during the tropical unit many patients complained of being stuck in the hospital during the festival time as this is an important holiday in the Nepali culture. Some of the patients were discharged after rounds, but others were kept for observation hoping to make it home soon. What I thought was interesting was when patients are diagnosed with diabetes they do not go through an education course, or get supplied with educational brochures. In the ICU unit I worked in a few summers ago we had a nurse specialized in diabetes and she would hold education meetings with newly diagnosed patients. The only education they receive is from the doctor during rounds. 

The other two days I spent time in the ER. Most of the patients I saw in the ER were motorbike accidents. The traffic here is insane. There are no rules of the road and no stop signs or traffic lights. It is a free for all on the road. Many patients came in with lacerations across their face, or their legs after having fallen off their motorbike. It is also festival season, so drunk driving occurs often which could have been the cause for some of these injuries. We had one patient come in with tuberculosis, but the problem with this is that there are no isolation rooms, there are no N95 masks, there is nothing here to prevent the spread of it. He had a history of TB but from what I could understand he did not take his medications properly. I avoided his area at all costs, not wanting to get TB or spread TB. 

On Wednesday of this week it was the day of goat sacrifices. We went around to the houses around our area and watched goats be sacrificed, shaved, butchered, and cooked. It was quite an experience watching these events take place. Family comes into town from other parts of Nepal and it is a huge family affair, very similar to stuffing a thanksgiving turkey in our family. The men all sit outside butchering the goat and drinking beer while the women are inside starting to cook the goat and prepare the meat to eat through out the whole day. For the next few days all the family does is eat goat, drink, and celebrate together. Kids are running around everywhere, receiving gifts from family and friends that come over to eat goat.

shaving the goat

shaving the goat

The sacrificial goat

The sacrificial goat

Carolin, the house we were at for the goat sacrifice, and Sandra my roommate

Carolin, the house we were at for the goat sacrifice, and Sandra my roommate

Then on Friday it was tika day. At 9:51am we started the tika, which was the set time for all of Nepal. The tika blessing starts with the eldest person in the family so for us it was a 84 year old grandma and she blesses every single person in the family starting with the youngest and money and fruit are given to you once she blesses you. Then the next oldest blesses the whole family, which was my host grandmother and grandfather. This process continues until the youngest couple blesses everyone. It took a total of two hours and half hours for the whole ceremony of tika and blessing. It was really special, and Binod, my host dad, blessed each one of us volunteers and blessed us wishing us the best in our career path, that we will be successful, and the best at what we do. There are so many people here at our house and at the festival activities. But now the festival has started to slow down. Although it lasts for 15 days, we will all be back to work on Monday, and all the shops will open again. Today we will be going to a special luncheon and the Kathmandu director will come down and have lunch with us and bless us with tika again toady.

my grandparents blessing me

my grandparents blessing me

my parents blessing me

my parents blessing me

Sandra and a new volunteer Tim

Sandra and a new volunteer Tim

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with my host parents

with my host parents

Tomorrow I will go back to work and start my shift in the ER! Later this week I will upload pictures from my trek in the Annapurna Region. 

 

Coffee and Cardiology

This week I spent my time back in the CCU, and for those who do not know or have not heard I have officially accepted a job at Vanderbilt University Medical Center in the CVICU. So being in the CCU is like being home for me, it is the place I love being and the place I constantly return to in this hospital. The CCU brings me much joy, and I love being able to treat and care for cardiac patients. I am very excited to start my career as a nurse, and being in Nepal has played a large role in the process.

Often times I participate in rounds and I look at monitors and assess what is happening and how to treat this patient. One day I felt like I was in a cycle of just standing there looking at monitors and listening to the rounds but I picked up on something. We were standing at the bedside of a patient and instead of a normal heartbeat on the monitor I heard a double beat with a pause and it continued this way. I was very confused as I had never heard or seen a heartbeat like that. I checked her chart and she had been diagnosed with bigeminy. After watching her heart rate, it was a regular rhythm then followed by a PVC, being diagnosed with ventricular bigeminy. She was placed on an amiodarone drip, which would help her irregular rhythm. When I returned to the unit the next day her heart beat had returned to normal sinus rhythm. Being able to see how quick a patient’s stability change is amazing. Although Nepal is low on resources and has limited access to man treatments, they have access to cardiac drugs, which in this case helped this patients bigeminy. 

We had another patient come in after he had fallen of the roof of his house. He is an alcoholic currently going through alcohol withdrawal. He fractured ribs 3, 4, 5, and 6. One of the doctors approached me and asked if I had ever seen a patient with subcutaneous emphysema, I said no. So he lead me to this patient and let me feel the air throughout his arms and shoulder from the trauma this patient had endured. During rounds the doctors discussed the placement of a chest tube as you could see paradoxical breathing and the patient starting to desat quickly, the nurses applied a face mask and the patients 02 saturation went from 54% to 100%. Since this patient did not have any cardiac issues the patient was transferred to the medical ICU to continue the treatment plan. The feeling of air in parts of the body where air should no be was weird and a little concerning/scary. It was similar to pushing on bubble wrap and feeling it pop underneath your fingers but never hearing the sound of the pop. He had bruising all over his abdomen, and favored his left side. 

Another patient had placental abruption at 34 weeks. She had a c-section and the baby is healthy, but since she was on warfarin due to her mitral valve replacement they had to wait so she wouldn’t bleed. She has mitral valve regurgitation and had a mitral valve replacement 12 years ago. They are constantly checking her PTT/INR to check when they can start her back on anticoagulants. Her heart rate has ranged from 75-175, she is often in tachycardia. Today was the first day where I saw her stay somewhat stable fro most of the day. 

This week I was able to go to the cath lab again and watch the placement of a PCI in the left anterior descending coronary artery. They first performed an angiogram, then proceeded to put the stent into place. As we were transporting the patient to the cath lab, the family was very distraught and upset. The wife was crying as she witnessed her husband go into the cath lab, hoping to be fixed. You do not often see people cry here in Nepal, even when a family member passes away. I have only witnessed two people cry here, and one was outside the hospital setting.

It has been a great week here full of coffee dates (much needed caffeine for a very busy week) and celebrating halfway points of friends. I am taking one of my two weeks of vacation that projects abroad allows since I am here for fourteen weeks, this coming week as another volunteer and I head to Pokhara to trek for 8 days! We are very excited and are excited to take a break from the hospital routine to allow us to rest and recover. I will be sure to write and post of my vacation time in the Himalayas, sorry there are not many pictures this week!

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There is a coffee shop located in the hospital and it has the best Carmel Macchiato, which provides me with some western food and comfort like I’m sitting in a local coffee shop at home :-)

Mental Health

This week I spent my week in psychiatry. During nursing school, I really thought I would not enjoy my mental health rotation, but I loved it. I never thought I would ever become a mental health nurse, but I always enjoyed learning about mental health. Mental health is so important and it is something as a nurse I will have to deal with daily both with my patients and myself. As I will become a CVICU nurse, it is important for me to know and understand mental health and how I can better help my patients who might be struggling with anxiety, depression, drug withdrawal, etc. 

Here in Nepal mental health is treated a little differently. There are no therapists or counselors. Many of the patients do not want to be admitted for a mental health illness so they leave the hospital and in most cases the ending is never good. With patients who are not admitted they come to OPD (psych outpatient department) for their “therapy” appointments. The doctor I am with this week spends half his week on the ward and the other half having interviews and conversations with OPD cases. 

The first day on the ward: there are no limitations the patients could have whatever they wanted with them. There are no restrictions. There are no sitters. All the patients are in the same room, there are visitors every where, patient’s spouses, children, parents, and patients with suicidal ideation have no limitations, where most patients in America with psychological issues would have sitters and not be able to keep their belongings in the room, depressed suicidal ideation patients would have strict limitations like plastic utensils or nothing in the room that they could use to commit harm. 

Some diagnosis include acute psychosis, bi-polar depression/mania, seizure disorder with psychosis, depression, schizophrenia, and anxiety. On the ward the patients really do not have therapy sessions. They have a “group” session of listening to music/dancing with all the patients in the morning but therapy really does not exist. The doctor will come in and have conversations with patients, especially new admissions about how they are feeling, what they think might have been a trigger, their mood, appearance, self care, etc. 

On the second day we went to a psychiatry seminar and learned about sleep disturbances and disorders, which was quite fascinating for me as I have had difficulty sleeping the past few weeks, but it is slowly getting better. We also got to watch ECT which was quite different than my experience with ECT during my mental health rotation. We got to talk with one of the patients after ECT, which was his fourth treatment. ECT takes places in the operating room here, possible because sedatives are used. I am really not sure as to why ECT took place in the operating room. Today we went to an anatomy class/lecture at the University. We went to the cadaver lab and the doctor talked us through all the parts of the body, the pathways, and how the organ works, which was a lot fo review for me, but I still love going to the cadaver lab and seeing real organs and real parts of the body. How the university receives the bodies for their cadaver labs is quite interesting. They contact the local police department and if a body has not been claimed by the family with in six months then the university can receive it for cadaver use. Many of the lungs in the cadaver lab were smoker’s, I have never seen such black lungs. You do not see many people smoking here, as many people do it behind closed doors, as well as drinking. There is a saying here that when the sun goes down Nepal comes out. Alcoholism, drugs, and smoking are big problems here. Many patients we see in psych are psychotic from drug withdrawal, or many depressed patients turn to drugs or alcohol. 

While in the psych department with another volunteer we have become to know the doctor very well. We have in depth discussions about mental illness, delusions, schizophrenia. The other volunteer and I even got to interview and discuss with one of the OPD patients about his OCD and anxiety. His spoke well enough English that we conducted the questions and then discussed with the doctor, and he would ask any questions we didn’t. 

Mental illness can effect anyone, and it is often a shamed illness but some many things play a role into why someone might be struggling with mental illness. It has been a great week learning more about mental illness and differences in resources and treatments here in Nepal compared to America. 

Updates: 

  • my friend Lilly left this week
  • I got to hold a newborn baby when I visited labor and delivery
  • We made aloo paratha 😍 

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New Life

I have had a lot of time to reflect on this past week in the operating theater aka what we in America call the operating room. I was going to add this to my gastro post, but the more and more I thought about it and processed what had occurred I realized it needed it’s own post. I think the biggest take away from this experience is life and death. In Ecclesiastes 3 vs 2 it says “a time to give birth and a time to die.”

When I think about all the surgeries and c-sections I saw this week I can only think of how life giving every single one of these surgeries were, but also how in one wrong step or wrong drug dose, or the patient having no surgery at all how it would be life taking. Patients with appendicitis, if they do not receive surgery immediately and their appendix ruptures, especially in a third world country, they will die. Each one of these appendectomies gave that person life, it gave that person another opportunity to continue on the path they are on, or maybe this surgery changed them, maybe after having the surgery they realized that life is short and I don’t want to continue doing what I was doing before, I want a new life. 

I watched multiple orthopedic surgeries. It’s very hard to watch orthopedic surgery. It’s very aggressive. Orthopedic surgery is probably the most fascinating because it goes all the way to the bone. The surgeons has to cut through layers and layers of tissue in order to get to the bone. His hands have to be precise. He has to be careful around veins and arteries. When looking at the X-rays all the patients have had breaks some were not so clean and others were very clean. Clearly seen from an X-ray. I have never seen breaks like this before. Watching the surgeon with his magical hands cut to the bone to then have to put it back in alignment and in place was amazing. It is tedious work and we put our life in the hands of this surgeon who for hours tries to fix you and most of the time the surgeon does in fact fix you and give you new life. These patients came into surgery, in pain, often times young kids, you could hear crying from any room in the OR, and they left surgery, fixed, made new, and having the ability of a new life. 

The other surgeries I watched were c-sections, and man oh man did they bring me joy. As babies were pulled out of the mothers womb and shown to the mom, tears were brought to my eyes. Watching them cut the umbilical cord and the baby being able to have new life without the mom, breathing on its own, it’s own blood, it’s own way of getting nutrients, everything is new. As they cleaned the baby up and weighed him or her I would pray to myself, thank you Lord for this child, I pray that they will be brave and that they will come to know you in a culture and society that is mostly Hindu. I wanted to scream happy birthday welcome to the world we love you. I wanted this child to know how loved they were, and how loved they will continue to be. I hope and pray they never lose sight of who they are or whose they are, as I hope and pray that for each one of us. 

“You made all the delicate, inner parts of my body and knit me together in my mother’s womb. Thank you for making me so wonderfully complex! Your workmanship is marvelous—how well I know it. You watched me as I was being formed in utter seclusion, as I was woven together in the dark of the womb. You saw me before I was born. Every day of my life was recorded in your book. Every moment was laid out before a single day had passed. How precious are your thoughts about me, O God. They cannot be numbered!”  Psalms 139:13-17 

I hope we don’t forget that even if we didn’t have a “life changing” (all surgeries are life changing in a third world country, but our lives can change even without a surgery being performed) surgery that we have a new life. We are given a new life in Christ, and that new life is like waking up on the operating table after a huge surgery has occurred in our heart and we enter into this new life, but we have a choice we can continue doing what we were doing and slowly fall back into our old ways, or we can change the trajectory of our life and run after Jesus and his grace, mercy, love, and faithfulness. 

2 Corinthians 5:17- This means that anyone who belongs to Christ has become a new person. The old life is gone; a new life has begun!

Colossians 3:10- Put on your new nature, and be renewed as you learn to know your Creator and become like him.

Being in the OT gave me new life I fell in love with this life giving experience and I think as a nurse I have that opportunity everyday to give a little more life to each of my patients. I pray that my patients make it. That they get to live and continue living, but there is a time to die. And death is closer than we think. We often fear death, but I think we should rejoice in death, rejoice in the life that was lived, in the person that lived it, and in the reassurance we will see that person again when we all get to meet Jesus and he throws a banquet and a party for us because we are home for eternity. 

We also have surgeries that are not life giving, where doctors and nurses try to save patients but they can’t. The patient doesn’t wake up from the operating table a new person ready for a new life, but instead wakes up to the face of Jesus (I pray that for everyone). Life ending experiences are hard, they hurt, there is grief, there is suffering, but we need to see there is hope. When Jesus’ life ended, he brought hope because in three days he rose again. We have hope in eternity because of Jesus, and with that hope we should live the best new life we can live, until there is a time for death.

These words do not do justice to anything I learned in the operating room. I learned more than I can process into words, and more than I will probably understand. I also don’t know how people can be in the medical profession and not believe in God. Everything about this profession is a spiritual experience, a place where you can be a light and a place where there are so many questions and so many things that are so intricate and perfect that we don’t understand. As I was talking to my mom the other day on the phone and I was having a slightly rough day I had told her the story of the joy I had watching a baby be born, she said heather on your rough days remember the joy of watching a baby be born, remember the joys of helping patients get better, that will help you get through the rough days, the good days make the hard ones worth it. 

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a Nepali minute clinic

A lot has happened since I have last blogged. I am now halfway through week 6 here in Nepal. I cannot believe how fast time has gone. I am almost halfway through my experience here. So here are a few updates before I get into the details of what is happening on the other side of the world.

  1. I am still not use to the staring, everyone stares, all the time, if you were to enter a staring contest with a Nepali you would lose
  2. There is no such thing as personal space, it does not exist, I am slowly starting to get use to that
  3. Sometimes you need American comfort food and for me that comes in the form of a snickers.
  4. I fall more and more in love with the country, this culture, and these people everyday. It is a pure joy and honor to work along side and serve this country and the Nepali people.
  5. On a clear day I can see the HIMALAYAS from the porch outside my room. THE HIMALAYAS PEOPLE THE HIMALAYAS. I CAN SEE THEM FROM MY ROOM, I am miles and miles away in the southern most part of the country, and I can see the most northern part of the country. Amazing.

On to the medical side of life here in Nepal. During week five I shadowed a gastric doctor in the OPD (out patient department). I have seen more butts and more GI tracts than I probably will in my whole life. It was very fascinating to watch endoscopies and colonoscopies. I have never witnessed them before so this was a first. The doctor I shadowed spoke very very very good English so it was easy to learn from him. Some common cases we would see are peptic ulcer from either H. Pylori or use of NSAIDS; many patients who would come in with gastritis would get a biopsy to test for H. Pylori. Hepatitis is very common here, mostly alcoholic hepatitis. We saw many patients that were alcoholics with jaundice sclera. Drinking in Nepal, as well as smoking, is a very common problem. The doctor describe this as when the sun goes down Nepal comes out. Cirrhosis of the liver is a problem here. Many patients I assessed had enlarged livers and enlarged spleens. Another common problem is GERD due to how spicy the food is here, the food is VERY spicy. Everyday we would go on rounds to the wards. There were a few cases of tuberculosis ascites, due to finding no other explanation as to why the patient has ascites, which I had never heard of so I did some research. You treat this the same way you treat TB with a six month medication plan, and if the ascites starts to improve you know it is TB ascites. To discuss what OPD is like would be like a CVS minute clinic on steroids. Patients show up around 8am in the morning and the doctor tries to see as many patients before 4:30, while also spending two hours on rounds between the gastro ward and both MICUs. It is a very stressful environment. It is not very private as people walk in and out of the office, sometimes even multiple patients sitting in the office while the doctor is discussing the illness of the patient he is currently seeing. The biggest learning experience for me during this rotation was we had a patient with an upper GI bleed. He complained of black, tarry, foul smelling stool. The doctor did an endoscopy and found the bleed in the first part of the duodenum. He injected epinephrine (they call it adrenaline). The patient was then admitted to the ICU and all receive a PPI drip. He will be NPO for three days. After many endoscopies and colonoscopies of people complaining of GI bleeds and finally finding one was very fascinating and exciting. As the bleed popped up on the screen the doctor and I said at the same time, there it is. During one of the colonoscopies the doctor was able to get to the small intestine. The inside of the small intestine looked like a fluff ball. All the villi on the inside excited and ready to absorb all and anything. I learned a lot in gastro about upper and lower GI bleeds, how you treat them, how you treat gastritis and GERD; it was a fascinating experience to be in the OPD with walk in, non admitted patients. 

where the upper GI bleed stared from

where the upper GI bleed stared from

This past weekend we stayed and Chitwan and explored some of the local sacred places and temples. On Saturday we took a magic bus to Devghat Dham. We hiked across a suspension bridge and back to the other side of the river where the temple was located. Devghat Dham. This area is located at the intersection of the Seti and Narayani Rivers and is one of the holiest places in Hindu mythology. On Sunday we went to Shashwat Dham. Shashwat Dham is a destination for all to attain spiritual strength, get exposed to the external knowledge passed over generation, and experience the true nature of our inner being which is love and joy.

These are pictures from Devghat Dham:

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These are pictures from Shashwat Dham:

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four are no more, time flies when you’re having fun

This is the end of week four. This past week I was in nephrology like I said before, but before the week was finished I switched units to the MICU. Nephro was very very very slow and there was not a lot for me to learn.

This week I am in the MICU. When I walked into the MICU I did not know what to expect. Honestly what I saw in the MICU, I expected to see in the CCU. All the beds were full. Half the patients were on ventilators. Patients were on drips, and almost all patients had central lines. When I first walked in they had just “bagged” a patient. The patient had passed away and the way they bag patients here is they wrap them up in the sheets, tape the sheets, label the body, and leave the body on the bed until their family member can come pick them up. If no family is present the patient is sent to the government hospital where they have a morgue. Since the hospital I am volunteering at is private they do not have a morgue, and the cost of treatment is a lot more.

There are currently four patients with H1N1, three of which are on ventilators.

Patient #1: This is a young female who had dengue fever, then got H1N1, an has bilateral pneumonia. She is sedated and intubated. She is not recovering very well but they are doing the best they can here. She gets turned every two hours and gets flipped from supine to prone every other day. I was very confused as to why a ventilator patient would be laying on her stomach. I don’t recall seeing US patients ever laying on their stomach with a vent, so I did some research. Research has shown that having patient on their stomach helps increase air distribution in patients with pneumonia. It opens up alveoli that would otherwise not be open due to pneumonia, and fluid. She does not seem to be improving and has been in the hospital for 16 days now.

Patient #2: Also very young, in her twenties. She contracted H1N1, then got pneumonia, which led to ARDS from being intubated. She is on a vent and for the past two days they have done weaning trials, but she has failed. She has been on a vent for 16 days, and they are discussing a tracheostomy. She is not sedated. She apparently went into septic shock as well, and had chest tubes in place. From what I could understand from the doctors was while she was being intubated she aspirated and got pneumonia, and that led to ARDS. The other day they weaned her and took her off the ventilator but then she requested to be back on the ventilator.

Patient #3: Also in her twenties, H1N1, pneumonia, and breathing rate of 55. This patient is not vented and is doing much better. She does nebulizer treatments daily, and those have helped slow her breathing rate down. She has a respiratory rate of 40-60 per minute. After the nebulizer her breathing slowed down a little but not alot to the middle 30s.

I got to witness an intubation here. The patient came from an outlying hospital already intubated so they were changing her intubation tube/reintubating her. The doctor stuck the metal rod that helps direct the ET tube down her already existing ET tube, then he took the old ET tube out and tried to place the new ET over the rod, but it failed. He then removed everything and tried to reintubate her. He tried two or three more times but couldn’t get it. He then finally got it on the fourth try about 15 minutes after initially trying to reintubate her. During the first reintubation the patient was not sedated, but after not being able to intubate her they sedated her.

I honestly cannot imagine being intubated without sedation or a paralytic. Most patients on ventilators here are not sedated, they are wide awake and functioning. Watching the intubation without sedation was very difficult. To see how the patient was reacting to having a tube stuck down her throat between her vocal cords was a very eye opening changing experience. If I ever have to be intubated, I would want sedation and a paralytic.

Today (8/29) I took a day of rest. I am working doubles this week making up for future days i will miss, but I woke up yesterday not feeling well. I didn’t sleep at all last night, and as I type this. It is the first time that I have energy again. Today my roommate left and I will be roommate less at least for a couple of weeks, which will be nice to just have sometime to myself and a little personal space. I loved having a roommate, but after not having a roommate for two weeks and then having a roommate, it will be nice to be alone again. Today also starts the festival for the birthday of the Hindu god, Krishna. We went to the opening ceremony this morning, and the temple is right behind my house. My host father is on the committee, and has helped organize the festival. They play music, chant, and talk at all hours of the day for the next seven days. It is amazing to see how passionate they are about the celebrations here. The kids start school later to participate, people skip work, etc. It really is amazing to see how dedicated the Hindus are to what they believe. It has challenged me to be just as passionate, excited, and dedicated to my faith, as they are to theirs.

I have been sick for the past three days and each day I’m slowly getting better and better. I have had a great friend and volunteer Lilly come visit me and hang out with me every day. She has taken care of me and made sure I had enough food and drinks. She has been my life saver. I am feeling a lot better just still very congested. It has been nice to be able to rest and reflect on my past four weeks here. I cannot believe it has already been four weeks. It seems like I was just being introduce and showed around yesterday. I have been able to talk to a lot of friends over FaceTime this week which has been a blessing. The weather here has gotten a little cooler, or maybe I’m just use to it now 😜 Being sick and basically spending all day in bed in a foreign country is different. It’s lonely, and quite boring. But my host grandmother has made me ramen everyday for lunch and it is almost like being sick at home. I have had a lot of time to read, sleep, and rest. I have gone through three rolls of toilet paper and my nose looks like Rudolph 😂

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This is Lilly! My hero! And my nurse!

My Nepali ramen that I have had everyday for lunch the past three days

My Nepali ramen that I have had everyday for lunch the past three days

Thinking about my past four weeks here is a roller coaster of emotions. From arriving and having a hard time adjusting to traveling every weekend, to being sick twice in a month, to visiting foreign doctors, to being home for the next four weekends. I’m loving it. It is hard. It is the most difficult thing I have ever done, but it is so rewarding. It is rewarding in the friendships, in the laughs, and in the smiles of every day life. In trying new foods, experiencing a new culture and being submerged in a new religion. It is challenging, but I am learning so much about life, medicine, and myself. I am having to rely on the Lord more than ever to give me strength, compassion, love, and energy to make it through the tough days, and joy and peace to make it through the easier days. What a wild ride these four weeks have been can’t wait for the next 10.

Time spent with these girls in the mountains

Time spent with these girls in the mountains

Nepali festival

All the volunteers with my host dad at the start of the festival

All the volunteers with my host dad at the start of the festival

Said goodbye to my roommate Natasha this week, she heads off to hike Everest Base Camp

Said goodbye to my roommate Natasha this week, she heads off to hike Everest Base Camp

Said goodbye to Margaux as she heads back to France, mon amie

Said goodbye to Margaux as she heads back to France, mon amie

Buddha Buddha Buddha Buddha rockin’ everywhere

This week I finished my rotation on the CCU and I have started my new week rotation on Nephrology. From the last time I have blogged a lot has happened. We had a patient who went to the Cath Lab for an angiogram, and I got to go with them. An angiogram is a diagnostic test where the doctor/surgeon will put a catheter in a patient’s femoral artery to look at the patient’s heart by injecting dye and taking X-rays. This patient is quite poor and his left anterior descending artery is narrowing and he needs a PCI, stent, but because he is poor he cannot afford the treatment, and therefore will not receive the treatment. The cath lab is a sterile environment, but sterile here and sterile in the United States is very different. I have made friends with two of the Nepalese doctor interns. They are the sweetest, and have helped me be able to see and do more in the hospital. We went to tea everyday in the hospital canteen, and one day they took me to lunch!

my Nepalese medical intern friends

my Nepalese medical intern friends

Medical interns taking my to lunch

Medical interns taking my to lunch

Tuktuk ride with medical interns

Tuktuk ride with medical interns

Another experience that occurred was my first code here. The patient was very sick. She had her mitral and tricuspid valve replaced many years ago. She had an AKI, pleural effusion, and hypothyroidism. She was in septic shock, and came to the hospital many days after she had already gone into septic shock. This was the first patient who had a central line and a ventilator that I have seen in the hospital. She was not on sedation, and I am unsure on how often they performed oral care, I only observed them performing oral care once. Her blood pressure was 64/34, and her pitting edema was the worst I had seen. She was restrained but her restraints were two fingers taped together, and then gauze between the two fingers tied to the bed.

This week I started nephrology. Most of the medications are in ampules, I was discussing with a nurse about syringe filters, but they do not use syringe filters like we do when we pull up medications from glass ampules. There were three patients on the floor that are receiving dialysis, they only do hemodialysis here. I felt the thrill and listened for the bruits. Last week there were two patients who had kidney biopsies. The cost of a kidney biopsy here is 14,000 rupees which is around $140. The kidney biopsy is sent to India, and it takes 10 days to get results. The patients in this unit look miserable. A lot of the patients have AKIs or ESRD. Many patients wait months to even come visit the hospital. I asked a nurse why it takes so long for a patient to come into the hospital, the patients believe that one more day they will feel better, and they will get better so they don’t come to the hospital. One patient with ESRD waited over a month to come to the hospital. It amazed me how long it takes for people to come to a hospital, especially with such chronic illnesses. 

This past weekend we went to Lumbini, the birth place of Buddha, which was over 100 degrees everyday. We arrived on Saturday after a 4 hour bus ride on a public bus with out it conditioning and more people than there were seats. Then we took the city bus to Lumbini which took an hour. That was the worst part of traveling, there were so many people, it was so hot, it was dusty, and it was dirty. We finally arrived at our hotel, and opted for a non-air conditioned room, which was great when we arrived because our room was coo, but by the time we go back to the room it was SO HOT. We got lunch and met up with a volunteer who had volunteered with projects abroad a few weeks before I arrived and she took us to Buddha’s birthplace and toured us around because she had done it the previous day. Buddha’s birthplace was something special. It was amazing to watch Buddhists in their home environment. We witnessed chanting, prayer, and meditation. We saw monks, and many prayer flags. The next day we went to see all the Buddhist monasteries that other countries have built in Lumbini. My favorite few are Germany, Nepal, and Thailand. They were beautiful, so much architecture and color. Each country’s monastery depicted their own Buddha, that represented their culture. There were Buddha’s and prayer flags everywhere, with sacrifices, gifts, and lots of food given to the Buddha. During our time in Lumbini, we saw a lot of poor people, beggars on every corner, but then you arrive to the monasteries and they are marble, and beautiful, you see both sides of economic status. It was truly an experience of a lifetime.

Buddha’s Birthplace

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Nepal’s Monestary

Nepal’s Monestary

Germany’s Monestary

Germany’s Monestary

Thialand’s Monestary

Thialand’s Monestary

City bus to Lumbini

City bus to Lumbini

Today my host family had a mourning ceremony. They are Hindu, so a year after a family member dies they have a ceremony and the whole family comes to town, so we have a lot of people staying at our house right now. There were probably close to 60 people at the ceremony, and close to 15 people staying at my house. My house dad invited all the volunteers, so we all went and ate with them for lunch. The food was so good! It was a really neat cultural experience to see the end of the ceremony and see my host’s family whole family. The food here is amazing. My favorite thing so far is shahi paneer, which is a gravy made up of cream, tomatoes, and Indian spices, with cottage cheese, served with roti, similar to pita bread! A lot of the food here is fried and oily, and there is not much meat, but the flavors are so good! 

This is shahi paneer with roti, not a great picture, but it is yummy food!

This is shahi paneer with roti, not a great picture, but it is yummy food!

elephant rides, magic buses, ear infections, and momos

(WARNING LONG POST AHEAD...if you want to skip the medical gibberish, read the first two paragraphs and the last one :))

also not sure how to move the pictures, so they are at he beginning (I am a newbie at this whole blog thing; I will also try to be better at taking pictures of what I talke about in the blog, something to work on for next week :-)

Chouen and I on our us ride to Chitwan

Chouen and I on our bus ride to Chitwan

Playing soccer/catch/monkey in the middle with my host family’s kids before going off to work

Playing soccer/catch/monkey in the middle with my host family’s kids before going off to work

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Elephant ride !

Elephant ride !

Somewhat of a picture of a magic bus, but also cows are holy here and this one was straight chillin in the middle of the street.

Somewhat of a picture of a magic bus, but also cows are holy here and this one was straight chillin in the middle of the street.

Making chicken momos!

Making chicken momos!

Fede, Lilly, and I at 20,000 lakes at Chitwan National Park (other volunteers)

Fede, Lilly, and I at 20,000 lakes at Chitwan National Park (other volunteers)

Here is an update as to how things are going here. I have been in Nepal over a week now. To say having to adjust would be an understatement as it has taken a while to adjust to life here. This first week was rough. Harder than any other week I have ever had but also the most satisfying and rewarding week of adventure, purpose, and friends. To start things off I landed in Kathmandu at 0900 Monday morning only to stand in line for customs for almost 2 hours. I finally arrived at the hotel I was staying at around 12:30pm. They asked if I wanted lunch and I politely declined and went to sleep until around 5pm. At 5pm another volunteer and I went to exchange money and buy a SIM card for my phone so I would have a Nepali phone while here. Then we went back to the hotel and I relaxed and journaled until dinner, which I did not eat. The first three days of being here I was anxious, nauseous, and couldn’t really eat food and the food I did eat I couldn’t keep down food. Tuesday morning I left with a projects abroad staff member, Shova, and two other volunteers, a high school volunteer from New York, and a nurse volunteer from South Korea, and 6 hours later we arrived in Chitwan, also very exhausted. We had an introduction meeting then we went to our host houses. I slept until dinner time, which I also did not eat, and the next morning I would start my journey as a nurse volunteer, and it was also the first day of a cold. So for the past few days I average 5hours of sleep a night, waking up from the hours of 1am-4am with very little appetite and basically no food in my system. Today (8/13) I found out I have an ear infection, more to come of this story later. 

After a rough few days of adjusting and trying to fight an illness, I began to eat again and participate in nursing activities. I play the role between a medical intern and a nursing student. I cant give medications but I can observe medical interventions/surgeries as well as perform ADLs and take vitals. I am currently on the CCU unit and will rotate through units every two weeks, as most of you know the CCU holds my heart and will hopefully be my home as a nurse back in the states. A little about the CCU unit here, there are twenty beds, about 3-4 nurses (they work 7hr shifts, and they work everyday), and about 3-4 doctors or medical interns. The unit does not have individual rooms but each patient has an individual bed. The patients are separated by curtains, which are only drawn if the patient is getting a bath or using a bed pan. In the morning we perform ADLs and vitas before the doctor rounds, after the doctor rounds the patient’s family members come to visit and ask the doctor questions. The families are very involved in the patient’s care and often perform the ADLs instead of a nurse. 

Some differences are there are no precautions ie. sepsis, MRSA, pneumonia. The nurses don’t take handoff report from one nurse, the nurses do rounds and get updates on every patient in the unit when they come on shift. Everything takes a lot longer here, from getting medication to receiving treatment. Treatment is based on the family’s economic status, if the patient cannot pay the procedure is not performed. There are no CRRT machines, there are no ventilators, and there are very few (1 or 2 patient in the whole hospital) central lines. The nurses and doctors wear hospital gowns over their scrubs/jeans and a T-shirt and they wear sandals. They also have very little health insurance here as many patients pay out of pocket for treatment, granted their treatment is very less expensive than American medical treatment, it is a lot of money to a Nepalese family. Another thing that is different is how their pharmacy works. There is no drug pharmacy for patients, in America we have something called a Pyxis, where you log in, click on your patient, click on their due drug, and receive their medications. Here the doctors write a prescription the prescription is given to the family, the family then leaves the hospital finds a pharmacy on the street (they are everywhere) and gets the medication. They return to the hospital and give the medication to the nurse to then deliver to the patient. 

Similarities are all patients in CCU have IV access, and patients receiving inotropic drugs receive them IV, but peripherally. Some research has shown that if inotropic drugs are given peripherally it can cause necrosis distal to the insertion of the IV, that is why many US hospitals deliver inotropic drugs directly to he heart. Since they do not have central lines they have no way of monitoring numbers ie CVP, PAWP, or PA. They determine how to titrate the inotropic drugs through ejection fraction by an echocardiogram, a normal left ventricle ejections fraction is 55-70%, most patients I have seen have 20-40%. 

One of the patients I really chose to focus on has been diagnosed with acute pulmonary edema, history of HTN, LVEF of 40%, chronic kidney disease, pneumonia, and ischemic hepatitis from LVEF of 40%. The patient has a history of a previous MI. Basically this patient is very very ill when I first saw him. Now almost a week later, he no longer as pneumonia, his AST and ALT (liver function tests) are decreasing in number, meaning his liver is starting to work better, and they are titrating his dobutamine and noradrenaline. They taper his drugs through monitoring intake, output, and blood pressure. 

I have really enjoyed learning the cardiac unit, and I look forward to what is to come the rest of the week. I had my own experience of being a patient at the hospital, but as an outpatient. As I stated earlier I have an ear infection. I started to not feel good a few days ago and thought it would go away with medicine and rest, but this morning I was sleepless and in throbbing pain, so I decided maybe it would be a good idea to get my ear checked out. I went with my host father to turn in all the paper work and then you receive this booklet from the counter and go to the outpatient unit of speciality, mine being the ENT. I went to the ENT around 9:15 and they said come back at 10:30, so I returned at 10:30 after the doctors had made their rounds and was seen by the ENT who then wrote a prescription in my booklet, that I then took to a street pharmacy after my shift. All of this cost less than one US dollar. So now I am medicated, and soon to be on my way back to being happy, healthy, heather! :) 

The title of this blog post is elephant rides, magic buses, ear infections, and momos. This weekend, if you follow my social media pages, you saw I went to the local national park. We went on a Jeep safari, a canoe ride, and an elephant ride, on an elephant we named Helen. It was a great weekend bonding with the other volunteers that I will being spending a lot of time with! Magic buses are the mini buses we take to and from our host family to work, they cost around 15 cents per ride. They stuff as many people as they can fit into the back of one which is around 10 people (I don’t think I have a picture, but I will try to take one and post one later). I have already discussed my experience as an outpatient and my ear infection, and lastly are the momos, the greatest Nepalese food. Momos are dumplings and they have chicken momos and veggie momos, this is what I have for lunch every day, when I am not eating a chicken basket (chicken tenders and French fries) from the coffee shop in the hospital. Sorry for such a long post, but a lot has happened since I have arrived, and I want this blog to be a place for me to be vulnerable and open about what is happening here and how I am doing.