Working at Green Pastures

Well its been seven weeks since I started work at Green Pastures (GP) so its time I let you all know how its going. My background is engineering in the oil and gas industry so as you can imagine trying to fit my experience into a medical environment is a bit like a square peg in a round hole. Fortunately the team at GP are great to work with and I'm enjoying the challenges of working in a totally different field.

So what does a mechanical engineer find to do at a hospital? Well GP has received some substantial funding for development and maintenance from a Finnish donor and a large chunk of my job is to oversee this work. The first few weeks has seen me putting together maintenance schedules for the numerous buildings around the site, creating concept designs for the new out patient department building that we're building and putting the tender together for the detailed design of the building. The current outpatient building at GP is not at all suitable for wheel chair users and other disabled patients which make up most of the patients at GP. The rooms are tiny and there are no proper toilet facilities. So we're building a new building that has nice big rooms with wide doors and wheel chair accessable toilets so that our wheel chair bound patients can recieve treatment without having to worry about how much water they drank before they came. At the moment we're going out for tender for the engineering and architecture of the building, we will hopefully start construction by the end of this year.

The slightly less glamorous side of my job is the donor work. GP is facing a huge budget deficit in the coming year and is desperately searching for funds to fill the gaps so while I haven't been fiddling round with floor plans or budgets I'm searching for new donors. At the moment I'm spending one day a week working in the INF Central office from which most of the donor team are based. So every Friday I cover my laptop in about three plastic bags and stuff it into my backpack and brave the monsoon showers on my bike for the 45 min ride to the Central office on the other side of town.

The entrance to Green Pastures Hospital

At my desk with my workmate Puspha 

Political Update

Its been a while since we wrote about the political situation over here, that's probably due to the fact that not a great deal of progress has been made. As I mentioned a while ago the deadline for the signing of the constitution has been and gone with no sign of a constitution. At the last minute the government and opposition parties agreed to extend the interim Constitution for a further year. During the negotiations the two main parties reached an agreement, part of which was the resignation of the prime minister within a few days of the agreement being reached. A few days turned into a couple of months and the prime minister has finally resigned. The president (I'm still not sure exactly what he does) declared that parliamentary elections for a new prime minister would be held. A two third majority is needed for a candidate to be declared prime minister. The parties went to vote last week (on the 19th I think) and the voting was split three ways. One third for the Nepali congress party candidate, one third for the Maoist candidate and one third refusing to vote. Another vote was called for last Friday, during the week leading up to Friday lots of negotiating went on between the two main parties and the various minority parties. On Friday voting was carried out again with a similar deadlock. Now the president has called for a third vote on the 2nd of August and both the main parties are trying to woo the minor parties for their votes.

It looks like this could drag on for a while, much like the constitution writing process. So in the mean time Nepal hasn't really got anyone at the helm, this doesn't seemed to have had much effect on life here but the longer it drags on the more likely it will so please keep Nepal in your prayers.

Working in the Nepali health system

As you probably know we have started work now. We are working part time and continuing to study language part time.

I (Jo) am working at the government hospital. In true 'lack of planning Nepali style' Gandaki hospital or Western Regional Hospital (WRH) was asked the week before I started as to whether they would like my services. The first time the head physio knew about it was when I turned up with the INF bosses to meet him!!

The physio who I met, Ajit, is the boss and there is one other physio. The week I started Ajit left for 1 months leave and the other physiotherapist left and moved to Kathmandu. A new physiotherapist who didn't know the hospital system started - and me who doesn't know the language or the hospital system!! There is also the assistant who does a huge amount of work and clinical discussion making.

The system is that the patients see the orthopaedic surgeon first. The 3 ortho surgeons see up to 200 patients in the four hours that the hospital is open. If they need physio they are sent to the department with a piece of paper with typically illegible doctors handwriting on it. A decision is to be made straight away as to the sort of treatment they should receive - different treatments cost different amounts, and then the patient is sent off to pay for this and returns. I often get the job of recording the patients name and telling them to go to the ticket counter for payment. I say it in nepali but as I am a white girl many people reply by saying I don't understand english and ask for an interpreter who says exactly what I have just said - only faster and with a nepali accent!

The patient then returns and I have decided that anyone could be a physio in Nepal. If you have a sore foot you have planter fascitis and therefore you have short wave diathermy - a treatment I haven't seen in NZ. If you have shoulder pain you have a frozen shoulder and therefore get exercises to allow you to move your shoulder through its full motion. Even if you come with an xray to show your joint is dislocated just do these exercises because even if it hurts now you will get better. If you have a sore back or neck you get traction with a machine.

To their credit there is no appointment system run and so at a time there can be 20 patients or more lined up and to give each one time is almost impossible.

The other role the physio is to do all the plaster work. If anyone has a fracture or needs a cast removed they come to us. They all appear to be cast the same way and most of the casting is done by the assistant who, once he has finished at the hospital works as an electrician!

The physios also cover all the wards of the 300 bed hospital (Taranaki Base has 215). There appear to be a lot of stroke patients coming through and they are seen once or twice and then the patient leaves as they can't afford to pay for the bed often without any sort of rehabilitation. In the outpatient department around 50 patients are seen a day. They work from 10am - 2pm as they are not paid much from the government so they also run private clinics. I am told that you treat private clients much better than public clients - you are welcome to shout at public clients as that is what is expected.

Another thing I struggle with is the different ways that people are treated. The villagers are rushed through without even as much as a 'namaste' but the hospital staff and friends of the physio staff are treated really well.

I am refusing to do the plaster work at the moment and therefore I take some of the exercise clients and give them a short assessment before trying to give them slightly more appropriate treatment based on my language and the scope I feel I have to work in as well as show respect for all the patients. I am also trying to get rehabilitation for patients such as the stroke patients so they don't go back to their village and die quickly from being unable to move so living in a corner of the house. In time I also hope that they may pick up some clinical reasoning skills - I think they have some but using them is hard work and recipe's are easier.

I will post photos later but the hospital is a concrete building and when I am told that post operative infection rates are high due to the cleaniness of the building I am not surprised. Parts have dripping water and mould growing - walk past that and you see a filthy room with a brand new and very nice looking CT machine!!! The xrays are in filthy rooms but again the equipment is state of the art - most of the xrays are OK to except that women don't take their jewellery off and the earring are so long sometimes you can't see a neck for all the earrings on the film!!

The ICU has flash beds from the west, nice monitors and then an oxygen bottle by the bed and no soap or towel to wash you hands but for infection control you have to remove your shoes at the door and then watch the staff put on gloves, touch a whole lot of equipment and then reuse a suction tube to stick down the throat of a patient with a chest infection!!! The patients wear a nappy that is used to hold onto to haul (I have deliberatly picked that word) the patient around the bed.

The hospital entrance

Patients queuing for treatment

Price list

The x-ray department, not much in the way of radiation protection

The physio department waiting room

Jo treating a patient

Rasoul explaining an exercise to a patient

The orthopedic ward, is pretty empty at the moment due to the rice planting season being in full swing

Power Struggles

We've been having all sorts of issues with power in our neck of the woods lately. They have been fiddling around with the power lines as part of the road works on our street. About a month ago a transformer blew up and we were without power for two days while they installed a new one. We ended up having a power cut party, this involves cooking up all the food in your freezer and fridge before it goes off and inviting everyone around to eat it.

Just when we thought everything had settled down there were problems with the new transformer and we lost power again for nearly two days. This time we put all our stuff in a friends freezer. That was fixed and then the other day we had a massive power surge which fried our fancy surge guard that Marion kindly carried all the way from New Zealand, along with the main circuit breakers for our house. We found out today that the voltage got up to 400V, normal is 220V. Quite a few of our neighbours fridges and tv's were destroyed. Fortunately our laptop that was running at the time was fine, I guess in that respect the surge guard did its job. We find it kind of funny that the wooden Nepali made surge guard (http://markandjoinnepal.blogspot.com/2010/02/water-and-power.html) survived without any problems.

Sign of the times...

We've been collecting photos of amusing signs since we came to Nepal heres a few of the best.

Update on the update on our bato (road)

We decided its about time we give you an update on the state of our road. Back in March we posted a blog about the mess that was our street. Four months on and our street is still a mess. Everything was looking really promising part of the street has even had a layer of bitumen applied so looks very spick and span but now it seems that the money pot has run dry. One of our Nepali friends told us the other day that the rest of the street is no longer going to be sealed (the rest being about three quarters of the street) so we're in for a boggy monsoon. Fortunately they are planning on putting a layer of gravel on top of the mud at some stage.

 This is what most of our road looks like after four months work.

  

After a rain shower

Constructing the drains with one of the local chickens keeping an eye on everything. Rocks are broken by hand and placed in line with concrete spread overtop. However, as the money dried up it appeared that there was less and less cememt put in and they are crumbling away very quickly.

The drains are really quite inconvienent especially if you own a car we've seen several people smashing them to get their cars out. They don't seem to have put enough cement in the concrete as the concrete crumbles when you touch it.

 

Digging a trench because what else does one do when its 35 degrees and really humid. Apparently its for phone cables

This part of the road is actually starting to resemble a street

And if you walk a bit further it starts to look like this. Gravel was layed quite nicely and then a layer of sand which was all rolled with a 100 year old roller (I wish I got a photo of the roller)

And then hand swept clean

A huge plume of rather toxic looking smoke drew lots of Nepalis to the bitumen factory. This is where the bitumen is made the way it used to be, right in the middle of the road.

Some of the bitumen was given to the man to spread (below) the rest was put in the trays in the back of this photo using the bucket on a stick method. That was mixed with stones and gravel to form the layer of tar.

And then laid the way it should be.....

I don't envy this man of his job, fortunately for him they've run out of money so he doesn't have to do keep doing this for another four months to do the rest of the road.

The layer of bitumen is about half a centimeter thick so theres a good chance that they'll be doing this all over again in another years time when the road falls apart all over again. Apparently it was done less than four years ago.

 

Kids playing next to the "bitumen plant" The pile of stones was what went into the large trays over the fire.

The mixture of stones, gravel and bitumen was hand delivered to site..

And then brushed over smoothly.

That is the finished product - a very thin layer of tar as the money has dried up - and it gets better - it is already breaking up in places - three weeks later.

Now that the money has run out the plan we heard was to put a layer of gravel over the surface. At the moment the road is a very slippery mud slide and the driest part is the drains! So, they called the digger back, he has completely broken up a part of the road below the original construction site - and is using the dirt from there to smooth out the upper part of the road!!!! And the story continues............