Annapurna GP – Working in Nepal

Tamara Keith / GP Trainee / Cambridgeshire.

Dr Tamara Keith used to be a Paediatric trainee in central London until she jumped ship to GP Land – going travelling en route. She’s now safely landed in rural Cambridgeshire where she lives with her husband Rob and mad Labrador puppy, Custard. In this article, Tamara tells us about her experiences of the Dhital Health Centre, and gives us some advice on working in Nepal.

Why Nepal?

I believe there are only two certainties in life: birth and death, the journey in between is up to you. Ever since qualifying as a doctor I had been waiting for an opportunity to use my medical skills abroad. I wanted to experience life and work in a less privileged environment than leafy West London. I left the UK in early summer to head for the top of the world, the Himalayas, to volunteer in Dhital Health Centre a remote medical outpost close to the Annapurna base camp trek route, in monsoon season.

How was the first day on the job?

After 3 days of travelling I arrived at my pre-arranged accommodation in the Annapurna region and realised the clinic was in fact an hour’s walk away and not the ‘advertised’ 15 minutes around the corner. It was admittedly around the corner, but there was a mountain in the way. Nevertheless the accommodation was great and the trek to the clinic each day one of the most memorable parts of the trip.

The first day I expected to be at the clinic there was a national strike so the clinic was closed. No problem – let’s do some home visits?! A local villager took me from house to house to various people he thought could do with seeing a doctor. My first patient was an 18 month old child, sitting outside in a hanging, swinging wicker basket. Her mother spoke no English but the gentlemen with me vaguely translated. The child had never eaten anything except breast milk. Bearing in mind in the UK we wean at six months this was a little alarming. Word had got around I was a Paediatrician, nothing like a complex nutritional case to get the mind working. The child was developmentally delayed and malnourished. I have never craved Dalivit (multivitamin drops) quite so badly. Nevertheless with a few tips she at least was eating some rice and milk over the next few days which was progress to get started on normal food.

What I rapidly learnt on this medical adventure was to adapt to the facilities and supplies available. There was no Dalivit, no breast milk fortifier, no community paediatrician to give developmental advice – I was it. So after seeing a few coughs and foot infections, I found myself homeward bound to my wooden house on the mountain side overlooking Machapuchare (“fishtail mountain”).

Then, a knock at my door.

“Can you see my child, we think she may have been raped.”

A heart-stop moment. What would I do if I agreed? There is no Child Protection Team out here, no swabs or forensic tests to hand. The mother spoke good English and after a full history and examination I concluded actually there was vaginal discharge, most likely vulvovaginitis from poor hygeine but no evidence of anything untoward. My first day was complete and I lay in bed wondering what the next few weeks would entail.

Tell us about the clinic

The walk to the clinic each day was spectacular, regularly seeing eagles, buffalo, snakes and walking in and out of the passing clouds. The clinic itself consisted of two rooms with an examination couch and a decent supply of oral antibiotics, analgesia and general wound care but anything further than that was not available. There were suture kits but no local anaesthetic, nebulisers but nothing to put in them and strangely endotracheal tubes but clearly no facilities to ventilate when at 2600m in a shack on the side of a mountain.

There was a nurse in the clinic who without me would usually run the medical centre on her own giving out medication as she saw fit to treat the presenting problem. There was very little in the form of documentation or examination of patients. She spoke decent English and would translate as I saw patients. As the days passed I encouraged her to examine patients more and document patients attendance.

The first two days were very quiet and I wondered whether I had wasted my time coming to such a remote clinic – where was everyone? I had been told it was 1 doctor to every 21,000 population in Nepal, bring me some patients! But oh, did they come. The following day there was a queue when I arrived. How? I asked. “Radio” was the reply. Radio? Oh yes, there was an announcement on the local radio hourly for two days that there was a doctor at the health centre.

As the days passed I saw a regular pattern arising – raining, no patients, sunny lots of patients. The medical variety included all ages from birth to late 60s (average life expectancy in Nepal being mid-60s) and a mixture of conditions from snake bites, presumed tuberculosis, burns, foot wounds and dental abscesses. It was like being a GP but a bit more tropical.

The nearest hospital was a 4 hour journey, involving a two hour trek down the mountain to the nearest road, so basically if there was an emergency if you couldn’t deal with it, it was game over.

Did you have any hairy moments?

There was only one real life or death moment after a child had an anaphylactic reaction to an MMR jab given at a government organised clinic. The nurse from the nearest city who had come to give the vaccinations had already gone, and with her the emergency bag containing the intramuscular adrenaline. Just as we were locking the clinic up for the night the mother came running up the steps clinging onto her child and shouting. He had swollen lips, widespread urticarial rash and was wheezing. What did I have at my disposal? A BVM, some oxygen, piriton, some out of date salbutamol nebs and a background in paediatrics. Over an hour passed of supporting the airway and the symptoms settled.

What was your most satisfying moment?

An elderly lady visited with her daughter in her mid 30’s, deaf and mute since birth. Her mother simply said “something’s wrong, I don’t know what but she’s not right”. Where to start? I simply did a thorough examination from head to toe and discovered the worst vaginal thrush I had ever seen so gave her oral fluconazole and topical treatment which hopefully settled her symptoms. A common condition in the western world, a simple treatment, but which to this patient promised an enormous relief.

Working in Nepal

Here are some tips from Tamara for those thinking of working as a medic in Nepal.

Pros

Cons

General advice

Don’t expect to change the world – take small steps, achieve small goals, you can’t set up Everest ER in a week. Some places will accept volunteers for anything from 2 weeks to a year. Offer the time you have available but appreciate the more time you give the more you will get out.

Don’t expect the same facilities, medication or support you have back in the UK. You have to adapt and improvise.

Expect to be independent and for patients to expect knowledge and advice from you, however junior you may be. You are a doctor, abroad it makes no difference if you are a registrar or an F1, the locals expect the same so don’t volunteer until you feel capable, able and competent to do so. It could be a terrible experience if you go too early in your medical career. This is not like an organised elective post where you have other doctors for support, here you are it.

Organising a medical placement in Nepal

You can pay various organisations thousands of pounds and they will find you a clinic, pick you up from the airport and sort your accommodation (just type medical volunteer Nepal and loads of organisations pop up) or you can like me organise it all yourself, save thousands and possibly have more genuine experience.

Locate a medical centre and contact them to see if they would like a medical volunteer – most will bite your hand off. The clinic I went to would like doctors or nurses who are confident in general practice type work including minor injuries and the odd emergency. At this clinic you treat locals only, it is about an hour off the Annapurna Trekking route. You are fully absorbed and welcome into local society.

Some medical centres will even provide free accommodation if you volunteer with them. Dhital health centre has a room attached where volunteers can stay. I was alone and the clinic is very remote so chose not to but if you were in a couple this would be feasible.

In most remote communities there are multiple guest houses and homestays which adds to the experience.

Practicalities

When to go / The best time is the dry season (October to April). I went in June, Monsoon season!

Working week / 6 days a week 10am-4pm

Religion / Hindu, Buddhist

Costs / Flight: ~£700; Accommodation: ~£5-10 per day (may include meals); Food: ~ £10 per day;

Nepali Currency / Only available in Nepal

Visa / Rules depend on where you are coming from. You can get tourist visas at Kathmandu airport, however you should not volunteer on a tourist visa

Licencing / Like the GMC there is the Nepal Medical Council. The clinic where you are going needs to organise registration, which for me proved impossible! For work in a hospital establishment it is an absolute requirement to be registered with the NMC. For work involving any surgery or invasive intervention it is a requirement. For volunteering in a remote medical centre like I did it was unusual to be registered and seems to be a grey area. No previous volunteer had ever registered however this does not mean that is correct so check with where you are volunteering before you arrive.

Vaccinations / Head to the travel clinic at least two months before: you need Japanese encephalitis and rabies for Nepal and these take weeks to get fully immunised. Also require – hepatitis A, typhoid, tetanus, hepatitis B.

Antimalarials / May be required, depending on where you are going.

Personal supplies / Regular medications, antibiotics for various diarrhoeal illnesses (azithromycin is required for Nepal, due to widespread ciprofloxacin resistance); mosquito net; decent torch (regular power cuts); ater purification system/tablets; Milton tablets – disinfect drinking bottles, plates, mugs etc.; decent waterproof clothing for the inevitable downpours; walking boots; inside/clean shoes or slippers; good personal first aid kit including nail scissors and tweezers; spare inhalers if asthmatic.

Clinic supplies / Try and plan ahead and contact the clinic and ask what items they need. If unable to obtain that information think hard about where you are going and the sorts of items that would be useful. The most useful item I took was an older fashioned sphignometer that did not require batteries, they cannot afford to replace batteries. I also took multiple pen torches which were useful as well as dressings for wounds.

Contacts

Dhital Health Centre / Contact Tek Nath Gautam, the secretary of the Community Health Centre  for advice on volunteering at the centre and advise on local accommodation (teknathgautam@yahoo.com).

Krishna Bk / Local trekking guide from the area around the health clinic can provide local information of where to stay, activities and treks when you have some time off (monenp2@yahoo.com).

British Embassy in Kathmandu / PO Box 106, Lainchaur, Kathmandu, Nepal. Tel (977) (1) 4237100 . BEKathmandu@fco.gov.uk.

Acknowledgements

I would like to thank the following people for providing equipment for me to take. Their generosity made work like this possible:

Oncall Medical Supplies Ltd, Exmouth

DS Medical, Fareham

The staff at Northwick Park Neonatal Unit, London

The MDU who gave me medical indemnity for volunteer work in Nepal at no extra charge