Photos by Nico Toutenhoofd
Getting ready to leave for Nepal
Monday, September 26th, 2016
Our bags are packed and we’re ready to go… Thanks, John Denver.
Nepal Day 1
Tuesday, September 27th, 2016
NYAGI Nepal Team 1 is going! Travel across the Pacific and Asia went without event. Arriving in Kathmandu midnight Sunday, Dhulikhel Lodge at 2 AM, we slept four hours and then shuttled to hospital to teach. The team arrived at the Dhulikhel Hospital to find a room full of eager nurses and Skilled Birthing Attendants – SBAs – who arrived three hours ahead of schedule, ready to learn how to save lives using ultrasound.
Introductions and greetings were followed quickly by group orientation and instruction in the basics of using the equipment and obNAV program. After lunch, three clinic rooms were provided for patient contact; a hallway of volunteers filled the space, all waiting for the chance to help teach and see their babies live using ultrasound. On to day 2…
Nepal Day 2
Wednesday, September 28th, 2016
Day 2 of instruction was another great success. We arrived to a room full of eager, smiling students from multiple regions of Nepal. We learned that some SBAs traveled for three days to this regional hospital center to participate in the ultrasound training. The curriculum introduced them to concepts of basic ultrasound technology, training software and iPad usage. Then we moved to three separate examination rooms for small group ‘hands on’ learning with volunteer Nepali women in various stages of pregnancy, some with wide-eyed toddlers in tow.
Midday we sat with our gracious hosts for traditional very tasty Nepali food. The afternoon lecture provided significant clarification of terms; we found the use of a baby doll quite useful. At every lecture our hosts help interpret lecture material, as some of the participants have limited understanding of English. At the end of the day’s learning the thirty donated iPads were individually distributed and received with great excitement. All participants were given ‘homework’ for the evening, which included searching the obNAV software for specific information regarding stages of pregnancy and clinical findings.
Prior to walking back to the hotel, the team was given a comprehensive tour of the large Dhulikhel hospital campus, which has been twenty years in the making, from a single small house to now a large medical complex still in various levels of construction. We were familiarized with the staff routine and invited to the daily “doctor’s rounds” tomorrow morning before class begins. The team debriefed until the wee hours of the evening, and woke again to the sound of monkeys and roosters in the forest and nearby homes.
On Wednesday, we look forward to meeting with Dr. Sharma, the Nepali in-country One Heart World-Wide director, who was instrumental in arranging our itinerary. The students will continue with their accelerated education, learning how to measure key fetal biometric markers like estimated weight, amniotic fluid levels, and technical pearls of wisdom for scanning. They will also explore the iPads and software in more depth. We are all excited about the magic happening here!
Nepal Day 3 – Day 4
Thursday, September 29th – Friday, September 30th, 2016
Morning didactic was followed by busy small group scanning sessions filled with pregnant moms anxious to get a scan. Every SBA had opportunity to use transducers and iPads, demonstrating new knowledge gained. A majority of SBA’s exceeded expectations and excelled past beginners ultrasound skill set. We were all impressed.
During scan sessions, multiple abnormal findings altered the course of individual patients’ lives. The students found:
Breech presentations in late term pregnancy, breech twins, an ovarian tumor, a non-viable fetus with no heartbeat, a pending miscarriage, possible ectopic, and abnormal retained products after recent birth. All diagnosed with ultrasound alone.
At the end of the clinic day, we were driven to Panouti, a nearby town untouched by last year’s earthquake considered a local heritage site of Nepali culture. The 4×4 bumpy 9 km ride was like a Disney ride in a foreign land, filled with bumps, sharp turns, with cows and dogs in the street and lines of wide busses squeezing past on what should be a one lane road. The NYAGI Team quickly got a taste of the travel challenges for pregnant mothers, even a stone’s throw from main highways.
Nepal Day 5
Saturday, October 1st, 2016
Our planned teaching agenda was modified due to facility and One Heart World-Wide administrators’ very busy schedule; another reminder that planning and expectations must always incorporate flexibility! Dhulikhel University arranged a beautiful conference room setting where all of the twenty eight SBA beginning ultrasound trainees could sit lining the room and each was called to front and center to receive their certificates of completion and iPad.
Drs. Cliff and Anjana shook hands with each program graduate and photos were taken, with much applause and gratitude. At the end of the ceremony one trainee blessed with the gift of song gave a beautiful spontaneous ‘thank you’ to the team in a haunting acapella performance which brought many of us to tears.
Nepal Day 6
Sunday, October 2nd, 2016
The team began our three-day excursion to the outskirts of the Dhulikhel-Kathmandu area. We boarded two 4×4 vehicles for the long winding, precarious journey on worn out, rutted roads no veteran of off-roading in Colorado would imagine. Dump trucks, jeeps, pedestrians and animals passed each other within a hair’s breadth of each other and the 500 foot precipice on the edge of the road. We got to two different birthing centers in fairly remote areas. We asked many questions of the local staff, and learned that the centers are essentially ‘open’ 24/7 for pregnant mothers to arrive in labor. We were sobered to learn that a woman in labor in a nearby village brought to the birthing center via a stretcher carried by four volunteer family and neighbors who are available at a moment’s notice. They often trek several hours to the center. Some women attempt to begin their journey and don’t make it, delivering along the way. Women are dependent on males in the area to motivate to carry stretchers.
Our One Heart guide for the trip, Bagawati, explained that most women in labor arrive to the clinic via stretcher carried by four men from the family, neighbors and friends. It is one thing to imagine and another to witness—as we prepared to load into our vehicles for departure we noticed some commotion down the hill. A group of men scrambling up the steep, muddy, washed out trail, carried a stretcher loaded with a woman in labor with twins from the village below. Few words can convey the emotion we all experienced during this moment. A couple of us thought to search for a camera or cellphone to capture the moment; most of us stood motionless, captivated by the power of this humbling scene. There were mostly men in this group of locals. We were told the patient had been seen in the clinic in the prior weeks, so she was known to be carrying twins. We learned that due to the twin pregnancy she would likely be taken via “ambulance” (a 4×4 truck outfitted with stretcher in back) the long bumpy drive to either Duhlikel or Katmandu hospital, a three hour minimum drive. We also learned most women are reluctant to go the larger hospital, due to the separation from family and less intimate nature of the care received there. The overall message was that the local birthing centers were familiar and more likely to draw the patient in for care.
The Melamchi health center greatly impacted the team on an emotional level. The center was very busy, and we were delighted to see one of the SBAs on staff that participated in the ultrasound beginning training program. She had already performed thirty-two scans that day before we arrived and told us that this was a typical load. Back in the United States more than ten scans per day is considered to be a lot. The conditions were challenging; the facility was cramped, dark and filled with patients waiting to be seen.
As we entered the facility we walked over concrete hallway with trail of dripping blood from a patient who had just arrived after a two hour walk from her village. She had delivered her first baby alone at home. There were two men home at the time, no women to help, and the men assumed “she would know what to do”. The baby did not survive and the placenta did not deliver, so she trekked – hiked – by herself, bleeding, to the birthing center two hours away. When we saw her she was lying on a stretcher, listless, receiving fluids via IV on a rusted pole. She was not very responsive to conversation, when someone swatted a fly off her face she did not seem to notice. We were unsure if she would stay or be sent home, or referred to another center for aftercare. It seemed they would attempt to deliver the placenta at the center and monitor her for a few hours afterward. We learned that in a typical delivery the mother is monitored for six hours and then discharged to walk home.
The clinic manager informed us of most common issues which would cause them to call for ambulance to the University hospital hours away: prolonged labor, breech presentation, postpartum bleeding. The day was capped at 4:40 am, when some of us awoke to a small trembler. The hotel staff told us that aftershocks from the major quake a year ago are so common that the locals have stopped keeping track of them.
Nepal Day 7
Monday, October 3rd, 2016
We arrived back in the capital city after two full days touring the remote areas of the Sindhupalchowk district. Eighty percent of the population here lives in rural areas – districts in Nepal are much like large counties in the USA; each has its own government representation and management. We were fortunate to have two skilled local drivers and knowledgeable tour guide who accompanied us to each birthing center. Our guide was a local employee of One Heart World-Wide, who is tasked with monitoring the daily progress, conditions, functioning of the various birthing centers scattered throughout the region. In this particular region we were told there were 70+ health posts, twenty one of which are birthing centers. All of the centers we visited were located atop large ridges or hilltops.
Most of the region is hilly and mountainous and the only open areas available for building are atop these steep inclines, meaning any patient must make the long climb to the center in order to receive care. A ‘health center’ is akin to our community health centers, and can address common health complaints such as pneumonia, diarrhea, traumatic injuries, etc. A birthing center has a designated area for labor/delivery, with SBAs.
We learned a great deal about the culture on our journeys. A high incidence (20%) of uterine prolapse is felt to be multifactorial: “too many kids too close together too much work too fast post birth”. The official average age of marriage in women is 19, but in rural areas more toward 14-15yrs of age. Often marriages are arranged by family. Families desire a male child; so if a woman gives birth to a girl (or four to five girls) it is expected that she “keep trying” until a son is born. It is illegal in Nepal for a clinician to divulge the sex of the fetus if it is detected, due to likelihood of self-abortion if the fetus is female. The more children in a family, the less attention, food, general care they receive due to limited resources. Malnutrition and infection are common. The arrival of internet, cellphones, and web access has decreased the average age of marriage due to more awareness of outside world. Family approval for marriage is expected. Women are reluctant to speak their husband’s name aloud; it was explained that this is due to combination of superstition and old religious cultural beliefs.
After completing our tour of various health centers and birthing centers throughout Sindhupalchowk, the team felt it hard to emotionally overcome some of the scenarios witnessed. We were given a tour of the local district hospital, which was hit hard by the earthquake last year. The main building was unsafe to inhabit due to large gaping cracks in the supporting beams and other structural elements. The current operating hospital consists of a small collection of tents: emergency, male outpatient, female outpatient, inpatient ward, pharmacy. The doctor in charge of the collection of tents graduated from medical school just three months ago and this is her first government assignment. Typically medical doctors receive financial support from the government so upon graduation are assigned to various locations for two years. They have no say where they will be stationed or for how long.
Upon reflection of our tour, it was clear that the array of health care centers from the hospitals to the community centers and birthing centers each had their own unique challenges and needs, from staffing to basic supplies such as medications, medical waste disposal/management, to ultrasound equipment and technical training to use it once available. We were all drawn back to our experience at Melamchi, a most powerful exposure which made clear all of the above. In particular, we were inspired by the presence of one of our NYAGI-Nepal Team 1 SBAs, who was performing ultrasounds on pregnant women packed in the clinic halls. That day alone she performed thirty-two scans. We felt that the NYAGI training she received greatly helped her appreciate what she was viewing on screen.
On the last day of touring we visited a general health center with birthing facilities which was further north closer to the Chinese border. This facility had one of our more advanced SBA trainees on staff. We were impressed by her knowledge of the ultrasound machine, and the educational obNAV software. It was apparent that she had been already studying the material, teaching herself more information from the available learning software. We were able to watch her perform a thorough scan. She could identify necessary anatomy, take measurements and assess whether they were within normal range. She also displayed highly professional patient interaction- something that was emphasized during the ultrasound training sessions. The overall impression of the team was that the training had maximum effectiveness in this particular center; there was a large patient flow with good oversight/management and it was clear that the knowledge of ultrasound positively impacted patient care.
We learned that the Nepali government pays pregnant women a stipend to deliver her baby at a birthing center or hospital. This is meant to financially motivate women to receive some oversight during the birthing process, as many women might otherwise attempt to give birth at home alone.
In all there were many things that could not have happened smoothly without the help of One Heart support—guides, translators, and escort to help with the flow of the mission. The trip itself, for the NYAGI team would not have been possible at all without very generous donations from local large medical device companies and especially private donations. The tour of Sindhupalchowk, for the NYAGI team, validated our feelings following the educational program that the fundamental goal of saving lives in remote areas was achieved and we are extremely grateful for all of the assistance that made this possible.
The One Heart World-Wide team in Nepal, and Sibylle Kristensen, affectionately known as the” One Heart complaint deptartment,” were instrumental in assisting our efforts in this mission. The coordination of the daily/weekly schedule, assignment of local staff, drivers, guides, offered a measure of support which made our maximum efforts possible.
The team leaves late tonight (Wednesday, October 5th) to begin our journey home via Hong Kong. We have incredible images to share which help convey the reality of the conditions and challenges faced by all of those trying to improve the resources here in Nepal.
- Team Leader: Cliff Gronseth
- Doctors: Nancy Franzoso, Cliff Gronseth
- Sonographers: Pam Brower, Emily Downs, Philippa Tatge, Ashley Upton
- Tech Support: Chris Paris
- Photographer: NicoToutenhoofd
… and all the kind donors to the NYAGI Project!
One Heart World- Wide Team
Dhulikhel Hospital – Kathmandu University Team
7Dimaging Inc. – donated obNAV Software
OtterBox – donated iPad cases