Jeremy and Michael's Medical Elective

Michael at hospital

Medical Elective Report - Jeremy S. (Cambridge Univerisity)

I chose Nepal as it was a country that I had been to before and one that I had fallen in love with.  From a medical point of view Nepal had the benefit of an English speaking medical profession mixed in with developing healthcare. On research into what medical opportunities were available I came across The Mountain Trust which runs health and education programmes throughout Nepal as well as internships for students interested in these fields.  The Mountain Trust was exceptionally helpful in tailoring the internship. I was originally planning to spend my time divided into on Neurosurgery, Paediatrics and helping with the UCL hypoxia study at Everest base camp. Unfortunately due to logistical issues I was unable to take part in the hypoxia study. Throughout the time I worked on a research paper and a chapter in a medical ethics book.

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The first of the placements of my elective was Neurosurgery in the CMS hospital of Bharatpur. Myself and Michael were under the supervision of Professor Cherian, a consultant Neurosurgeon who trained in India and had a special interest in vascular neurosurgery. The CMS hospital was one of three neurosurgery hospitals in Nepal, it took patients from a large part of southern Nepal. The Neurosurgery department consisted of an operating theatre, neurocritical care unit, an HDU and a standard ward. The department was young and developing; only in it’s third year. My typical clinical working day was morning ward round, followed by some teaching by one of the registrars, and then the surgery list. I did not really know what to expect but I think I was initially surprised how advanced some areas of the Neurosurgery department was. In the operating theatre there was a new fully mobile operating microscope with plasma screen so the students and junior doctors could observe microvascular surgery. The quality of the radiological images from the CT and MRI machines were also of a high quality. The ITU also seemed to be kitted out to in order to deal with complex neurosurgical patients. However as the weeks progressed it became apparent that this developing department is on its way to offering treatment comparable to that usually found in the UK, but it has a way to go. A number of factors made it difficult for us to get involved as much as I would have liked: an outbreak in meningitis meant that the surgeons did not want us to scrub in or help with procedures, something that I was really (if a bit naively) looking forward to. Having said that, the high patient load meant that I was exposed to many different Neurosurgical presentations making the clinical side of this placement valuable. I also learnt the value of teamwork and maintaining an effective team dynamic with mutual respect.

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 My most memorable event occurred during this placement. This was when we were called to emergency surgery for a child who had been hit by a motorcycle and had sustained serious head injuries including a huge subdural haematoma. Unfortunately the hospital does not have its own blood bank and we had to wait for about one and a half hours before blood arrived from a hospital nearby. My lasting image was of this small child lying unconscious on a trolley with no one next to him whilst everyone waited. He had the surgery but was still in ITU when we left 2 weeks later.

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Surprisingly I found that the help with research and literature review that we did in the evenings the most educational. This comprised of two pieces of work: a chapter on ‘Dying with Dignity’ in a Neurosurgical ethics textbook and a paper on the grading of sub-arachnoid haemorrhage. Both of which provided extremely useful learning opportunities. The initial task given to us was the chapter. The palliative care teaching that I had been to as part of the Cambridge medical course provided a valuable base on which to build, in fact I feel that we were able to share knowledge on this subject with some of the Nepali doctors working alongside us. This task allowed me to reflect on, and expand my knowledge of palliative care.

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The paper on sub-arachnoid haemorrhage presented a different challenge. Here we were given the results of a large project (1565 patients across 40 institutes in Japan) and were tasked with writing a publishable paper. The aim of the research was to alter the World Federation of Neurosurgeons grading system of subarachnoid haemorrhage so that it was more effective at predicting patient outcome. Doing the write up made me realise how much work and collaboration occurs when writing a paper. We were constantly writing and receiving emails from various professors and statisticians from Japan in order to clarify areas that we were unsure about. The write up has required a large amount of effort even now that we have finished our elective, but has allowed us to develop valuable skills in this area of medicine. Both the chapter and paper was written with Michael and myself, I was surprised how effective it is writing in partnership. It was easy to bounce ideas off one another and I feel that as a result the end products were much clearer, more precise and more concise than if either one of us had written them separately.

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The second placement was in Pokhara in a new hospital (only 6 months old) that specialised in Child and Maternal health but also catered for general medicine. Here I spent most of the time in clinics as well as small ward rounds.  The Doctors were much friendlier than at the previous hospital and I feel that the relationship with the nurses was good. This led to a welcoming atmosphere as well as a holistic view of patient care. The clinics were valuable learning opportunities as there was a large patient turnover and many patients were good to examine due to the presence of signs that are not common in the UK (e.g rheumatic murmurs). One aspect of this part of my elective which most stood out for me was the approach to healthcare of the patients. They were often reluctant to take medication especially if it was for a disorder which did not have visible symptoms such as diabetes or hypertension. They were also often unwilling to give birth to their children in hospital, so much so that there is a government programme to give 1000Rs (roughly 8 pounds) as an incentive to any mother to have their child in hospital.

The final part of the elective was spent in community health camps as well as school education programmes. On a typical health camp we would go to a small, inaccessible village in a 4x4 and offer clinics with free medication. The clinics had two doctors a gynaecologist and general physician. Once again there was ample opportunity for myself to hold my own clinics with a translator. Here I improved my examination skills, and in particular my concise history taking as the clinics were quite time pressured. Myself and Michael also did a questionnaire in order to assess awareness of hypertension, the serious conditions that it is associated with, and the attitude towards medication used to treat it. We are aiming to write a short article based on our findings.

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The education programmes were run by the Mountain Trust. It runs scholarship programmes that help to pay for stationery items and uniforms in order to encourage parents to send their children to school. We took part in an evaluation of the scholarship programme to ascertain if there were ways to make it more effective. I feel that in the long term education in this part of Nepal is the most effective way to improve the health of the population. As with the rest of the world, poor education is inextricably linked to increased morbidity and mortality. Funding children through school increases the chances of them working their way out of poverty and therefore decreasing the illnesses associated with it.

In conclusion, I had a fantastic and highly varied time in Nepal. I would recommend it to anyone who is interested. I feel that I have learnt a great deal and the experience has been great preparation for my final year of university studies and future medical career.

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