Back in Kathmandu

So we're back in Kathmandu after having a great experience in Pokhara interacting with FCHV's (Female community health volunteers), medical officers and surgeons. Being in Pokhara was an amazing experience, not only because of variety of health workers we got to meet, but also because of the awesome views, and fresh air! We got to experience walking through rice fields in the rain to get to a health post (and I almost lost my shoes in a stream); which showed us the challenges that people in these rural areas must face to access healthcare. I must admit that although we're glad to be back, we did not miss the smog filled Kathmandu air.

Today was one of the most productive days we've had thus far! The team returned to Kathmandu Medical College to meet up with general surgeons and physicians in the OBGYN department. The MIS team observed a rare esophageal stricture removal, 2 cholecystectomies and a rectal prolapse procedure (all performed laparoscopically); while the Preterm team observed a delivery and got to see the NICU. Unfortunately, Allie was unable to join the us today due to a stomach bug which she acquired after drinking a glass of lemonade with ice last night at dinner. Allie's episode which lasted about half of the day just reinforced how important it is for us to order drinks without ice, or only those made with "mineral water" ice due to the poor quality of the regular Nepali water.

The MIS team met up with Dr. Thapa, a general/GI surgeon, who has introduced a number of different procedures including the use of the SILS (Single Incision Laparoscopic Surgery) port to Nepal. He is a very enthusiastic man, and was willing to answer all our questions and introduce us to his team of 6 surgeons. Dr. Thapa received his training in India and has since traveled to different countries including the United states to learn  how to perform other procedures by observation. Coincidentally, Dr. Thapa had recently received a SILS port from one of the CBID clinical mentors, Dr. Nguyen.

From our observations and discussions with the surgeons, we were able to gain insight into the training pathway to becoming a surgeon as well as the barriers to MIS specifically related to cost, and usability of the equipment. Most surgeons at KMC are confident in performing laparoscopic cholecystectomies, due to the amount of experience they have had over the years (in spite of their limited instrument set). They also perform several appendectomies, hernia removals, cancer surgeries and gyn procedures such as cyctectomies and prolapse procedures. Nevertheless due to cost limitations, surgeons have been forced to create their own innovations such as to use cheap meshes (or no mesh at all) with regular sutures instead of staples. The hospital relies on donated laparsocopic instruments, and is only able to purchase OM surgical tools from India

Because surgeons are paid a fixed salary of $500/month at KMC, Dr. Thapa and his collegues spend the afternoon working at Grande International hospital, a private profitable hospital in Kathmandu, which we were fortunate enough to visit.Unlike KMC, Grande hospitalis equipped with state of the art machines such as CT scans and MRI machines. The OR rooms are comparable to those at hopkins and satitation is taken very seriously, hence the team was not allowed into the NICU.

Our night ended with a wonderful diner and insightful conversation with Dr's Thapa and Dhiresh who have published a book and several papers on surgery together. Coincidentally, Dr. Thapa will be in the US later on this year and would love to speak with CBID students.

Here are some insightful quotes form our conversations with surgeons:
"We don't compromise on patient safety, we compromise on our comfort to reduce cost." Dr. Thapa
"Nepali people have a high immunity, that is why our infection rates are so low. I just change my clothes to keep the blood off, not because of infection." Dr. Thapa
"When your hands are free your mind is free."  Dr. Dhiresh
"When performing MIS, your mind and your assistants mind have to be in parallel." Dr. Dhiresh

The team with Sheetal from Jhpiego, and Dr's Thapa and Dhiresh from KMC after dinner.