Mark and Jo's Nepal Mission Trip: 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.