I always wanted to do my elective in South Asia as it’s close to my home, India. I had already done a few placements at home in India and wished to explore the neighbouring countries. This made me choose Nepal, more so when I saw it listed on the Work the World website.
I spent 6 weeks in the city of Pokhara. My first two weeks were spent in the department of anaesthetics.
I got the opportunity to assist with pre-op assessments as well as take detailed histories from the patients. I was aided by the junior doctors and registrars who helped with translating.
The first couple of days I observed the various anaesthetic procedures before, during and after the surgeries. After this, I was able to assist with certain procedures. These included IV cannulation, fluid administration, airway management and inducing general anaesthesia.
It was interesting to note the differences between our protocols in the UK and the ones followed by the Nepalese doctors. In Nepal, they did not use fluid balance charts or drug Kardexes and everything was recorded in a patient’s case file instead. There wasn’t a separate sharps disposal kit and their version of NEWS charts were less detailed which could result in early warning signs being missed.
The most striking aspect was that they did not use the WHO sign in/sign out checklist for the operations, which I found quite surprising as I thought it would have been implemented worldwide by this time. This made me appreciate the attention to detail and provisions for safety back home in our NHS, especially for surgical procedures.
The next three weeks were spent in the emergency department. I found it easier here because the guidelines they followed were very similar to the NICE guidelines back in the UK.
It seemed a person’s social class determined the level of treatment they got.
The only difference I noticed was that the most ‘cost-effective’ option was given to every patient because certain drugs were expensive for the hospital. It seemed a person’s social class determined the level of treatment they got.
The emergency medicine scene in Pokhara had similarities and differences to A&Es back here in the UK. It was slow in the mornings but picked up pace in the afternoon and was always packed in the evenings.
The most common presenting condition was weakness and/or immobility due to a stroke. These were always patients with a history of severe hypertension.
Unlike our NHS, the healthcare in Pokhara was not free at port of call. Even in A&E, the treatment a patient received was according to how much they could afford. Thus, the first line treatment for an ischaemic stroke, thrombolysis, was given based on how much one can afford. The recommended drug, alteplase, was used only if affordable for the patient. The other, cheaper, option is streptokinase but it had to be given via slow infusion over one hour and this hampered improvement and treatment in an already deteriorating patient.
Another common presentation was snake bites, something which is literally unheard of back in Belfast. Thankfully most snakes in the region are green vipers and not poisonous; their bite just causes inflammation which is controlled using magnesium sulphate infused bandages.
I always looked forward to the evenings and especially the weekends during my time in Pokhara. The Work the World team in Nepal were locals and as such recommended outdoor treks and other such activities to keep ourselves occupied.
Along with other students in the Work the World house, I covered all the treks in Pokhara, went river rafting (something Pokhara is famous for) and also went bungee jumping! The only limitations on fun are what you place on yourself and Pokhara is perfect for the adventurer in everyone!
Pokhara is set against some very serene backdrops and exploring these added a whole new element to the word ‘exploration.’ The locals were some of the nicest people I’d ever come across and somehow always knew when us foreigners were lost!
It did get repetitive initially but once I’d left Nepal one thing which was definitely missed was the delicious ‘Dal Bhat’, a traditional local dish.
Village Healthcare Week
For the last week of my elective, I was at a healthcare outpost in a village situated 3 hours from Pokhara. This was an eye-opening experience and made me appreciate my privilege.
The health post was not only in an underdeveloped region (healthcare wise) but most of its occupants did not have the means to travel or seek better forms of treatment. While most people could afford to go to the nearby district hospital, there were quite a few who could only seek healthcare from these outposts.
The main presentations were sore throat, tonsillitis, headaches and gastrointestinal problems. I assisted with taking histories, measuring blood pressure and giving patients lifestyle guidance.
BP tablets were hardly prescribed as firstly, they were expensive (even though these outposts were run by the government) and secondly the locals were mostly noncompliant.
As some of them could not read and write, the doctor and I showed them the required lifestyle changes and advice through the use of picture books.
My time in Pokhara and the village allowed me to build upon my history taking skills as well as the ability to quickly come up with differential diagnoses and their effective, affordable treatment.
I also realised the differences in healthcare provision between Northern Ireland and Nepal and that the doctors in Nepal have to consider treatments based on the patient’s affordability and hospital’s allowances.
While I was nervous at times, it helped me build my confidence in practical skills and enabled me to trust my abilities more. Overall, my elective experience was holistic and made me appreciate those things which I often take for granted in the NHS.