Manipal Teaching Hospital- Pokhara, Nepal

So I finally made it to the hospital, after a 3 day journey to the other side of the world. My first day was orientation and my first clinical shift in the Emergency Department here at Manipal Teaching Hospital in Pokhara.

A little background: My amazing EM Residency Program at UTH has an international medical rotation elective available as well as an International Medicine Fellowship. I'm at the end of my PGY-2 year at UTH and I wanted to do international medicine as my elective. Our current 2 sites are Fiji and Nepal (which is a relatively new development for us). The benefit to coming to Nepal is that it a less developed country and has more limited resources, which is more aligned w my interest in EMS and Wilderness Medicine.

My first clinical shift was 8:30am to 4:30pm local time on a Friday. When you first walk into the open air hospital, it is a buzz w activity at the front desks w billing, pharmacy, registration, lab testing, outpt clinics ect.

Main entrance

Main entrance. The billing and registration counters are on the left.

Just off to the right of the main entrance way and down the hall is the Emergency Department.

The main ED has 10 beds, an observation unit with 4 beds, and another room outside the main department around the corner with about 8 beds next to each other for observation and short stays (24 hours or so). The equipment and supplies are pretty "archaic" by US standards and include: 2 cardiac monitors, 1 EKG machine, a defibrillator machine, and 2 supply areas.

One of the two sides of the main ED, note the cardiac monitor on the wall.

                         

  This is the EKG machine. The clothes-pen things go on the wrists and ankles and the little blue things are the other leads that get suction cupped the the pt with a small amt of gel.

Suction cup EKG leads

"Crash Cart"

Crash cart, cardiac monitor, suction and oxygen on the wall

Supply area with medicine cabinet on the left side of picture

The other supply area.

They also have a procedure room

Procedure room supplies and sterile suture trays.

View from the nurses station. All pt records are hand written. The pt is given their records at the end of discharge to take home. Most pts come in w a baggie full of old pt records. There is no such thing as electronic medical records or any rules about the facility storing records for 10 years. There are also no law suits against medical providers. One of the nurses tells me that if a pt deteriorates or the family is upset about care, the family may just punch or physically assault male doctors or nurses (but the is extremely rare). The ED also has a video camera that they use to review any such incidents.

In order to have 2x2 gauze, they take a large swath of gauze, cut, and hand fold to size. The only box of gloves they have is a box of sterile gloves. Generally, the only time medical staff wear gloves is to start IVs, drawl blood, and give IV or IM meds.

As far as patient's and volume goes, the nursing supervisor tells me that there are about 55 patients per day, and about 10-20% are admitted. They get very similar cases as in the US: SOB, chest pain, weakness, fatigue, AMS, COPD exacerbation (very common due to smoking and air pollution), CHF, strokes. They also get trauma cases depending on time of day/week such as scooter accidents, assaults, GSW, stabbing, falls, struck by lightning (this is the beginning of monsoon season). The one strange thing is that most pts present one or more days after incident bc it takes so long to get to a hospital from the surrounding villages.

This 700 bed hospital is run by an Indian University under a 50 year contract, and most teaching physicians are from India. As the largest teaching facility in the region, this hospital has one of only two 24 hour EDs in the region and has most of the major specialties including: cardiology, CV Surg, GI/hepatology, nephrology w a dialysis center, neonatology, neurology, neurosurgery, orthopedics, oncology, plastic surg, OB/GYN. It also has 50 ICU beds including MICU, Surg ICU, neurosurg ICU, Cardiac ICU, PICU, NICU.

The ED is staffed by nurses, nurses in training, interns, and one medical officer (attending physician). There are several international nursing students rotating through for a week or month at a time. The hospital is home to a nursing and medical school. The medical school is 5 years long followed by an Intern year. After intern year, the new doctors can either specialize as a resident or they can begin practicing on their own in general medicine.

They have a CT scanner above. They also have a MRI, US, xray for imaging.

One of the radiologist reading a CT head. All xrays/images are printed onto hard copy "old-style" films for clinician review. The only computerized version is what the radiologist reads off the machine as above.

This is one of the local ambulances. Unfortunately, there is no centralized 911 system. Most hospitals own 1-2 ambulances that patients can call for transport, but it is extremely expensive for the patients and the ambulance is typically only staffed by a driver who knows little about first aid or EMS care and the only supplies is typically a tank of oxygen. There was a recent local article published discussing the misuse of these ambulances to transport staff, goods, or to run errands for the hospitals. www.ekantipur.com/the-kathmandu-post/2014/03/22/news/ambulance-misuse-on-rise-in-pokhara/260730.html

My first shift went smoothly. I mostly observed as pts came with SOB, weakness, ETOH withdrawal, hypogylcemia, CVAs, and weakness. The patients all speak Nepali, and most medical staff are fluent in English and Nepali. This is already an amazing and enlightening experience.