Photos by Jason Houston
Day 1: Arrival in Nepal
Saturday, June 3rd, 2017
Despite the mayhem of rounding up fifteen volunteers from locations scattered across the United States and flying them halfway across the world, somehow the entire NYAGI Project’s Team 2 managed to arrive at roughly the same time to the airport in Kathmandu, Nepal.
Luggage piled high into the back of a pick up truck and secured by tarp, we bump through the streets of Kathmandu. Our destination is Dhulikhel, Nepal, roughly an hour to the east on pitted, winding roads into the foothills of the Himalayas.
Traffic laws seem nonexistent. As we careen about the crowded streets, sounds, colors and smells overwhelm our senses. The driver shouts a warning to, “Please keep your arms and legs inside the vehicle at all times!”
Eventually we arrive at the hotel, a cozy set of buildings painted in vibrant yellows and oranges complimented by flowers of every color with the stunning spine of the Himalayas as the backdrop.
Though our intrepid group is exhausted, jet-lagged, and heavily-laden with donated iPads and portable ultrasound machines, our true journey is just beginning:
Helping to save lives with ultrasound in remote, resource-limited areas…together.
Filled with beauty, friendliness and adventure, Nepal is firmly classified as a resource-limited country with a healthcare system that lacks access to the technology that the western world often takes for granted. Expectant mothers and their children are especially at risk due to many of the unforeseen complications that can develop during childbirth.
Jason Houston, the team photographer, aims to capture the zeitgeist of rural mothers in Nepal while the team teaches the ultrasound course. Indira Khatri, 23, had her second child four days ago. She lives is Thokarpa, Nepal, an hour walk – there are no roads – up the steep terraced hillside to the nearest clinic, and four to five hour drive, first on a rock strewn and mud slicked ‘road’ switchbacking down the valley, then the final stretch on mixed paved and dirt roads, to the nearest hospital. Her first child was born premature, but luckily she was in Kathmandu at the time where her husband sometimes works as a truck driver. They stayed in intensive care for about a week but had to go home early when the big earthquake hit in 2015. She was worried about her second child and went regularly to the local clinic for check ups but in these resource-limited remote villages, even the best care is severely lacking even basic diagnostic and preventative tools like ultrasound.
This is why we’re here for the next week. Indira’s story is similar to many other mothers in Nepal who would benefit from ultrasound technology, but whose remote location and the inaccessibility of roads in the event of rain make getting help for labor and delivery extremely difficult. NYAGI’s aim is to represent that pregnant woman in remote, resource-limited areas who may die from a complicated pregnancy and delivery. Ultimately, we all work for her.
Our mission while here in Nepal is deceptively simple: teach the basics of obstetric (OB) ultrasound to a group of Nepali healthcare personnel in just five days, so they can then in turn use ultrasound technology for prenatal care in remote regions.
Why ultrasound? Ultrasound is ideal for use in remote areas: it’s inexpensive and lightweight while providing dynamic imaging in real time via harmless sound waves. When used fully, ultrasound technology can act as a modern-day crystal ball, predicting future trouble in advance and thereby potentially preventing death.
It’s a wonderful feeling to be able to proactively save lives with the power of ultrasound.
To that end, we’ve brought thirty donated iPads preloaded with obNAV – an in-depth, interactive ultrasound training app that functions like a “pocket professor” so they can continue to learn from even after the team has left – in addition to portable, handheld ultrasound machines.
Making sure they know how to use this technology – iPads, probes, and obNAV – is just as important as making sure that they know the position of the placenta and the amount of amniotic fluid, among other things. As a team, it is our job not just to make sure that our students know what to look for, but also how to look for it, realizing the full potential of ultrasound technology.
Before the teaching course at Dhulikhel Hospital officially begins, the team departs on a road trip to a remote clinic located in Melamchi, roughly a twenty mile trek from Dhulikhel. Despite the relatively short distance, the journey takes two hours on winding, pothole- and pedestrian-filled roads that would challenge most Western drivers. The Nepali drivers, however, navigate the road with skilled precision, calm even as two wide buses deftly slide past each other on a narrow road bounded by steep cliffs. While the ride is mildly frightening, the views along the journey are spectacular with vibrantly green, rolling hills and sharp mountains covered in a thin layer of fog.
Upon arrival at the clinic in Melamchi, we pull up at the same time as an ambulance carrying a nineteen-year-old woman, her three-day-old newborn baby, and her mother-in-law. After an arduous four-hour ride to the Melamchi Clinic, bleeding and suffering, the new mother is examined via ultrasound and then sent out again, this time to Dhulikhel Hospital, for more advanced medical care.
Stories like this are not unusual here. During a tour of the clinic, we learn that many patients must travel for hours – usually on foot – for diagnosis, treatment, and, in many cases, examination via ultrasound. Some have appointments, but most are walk-ins.
Many patients must travel for hours – usually on foot – for diagnosis, treatment, and examination via ultrasound.
There are a few buildings nearby providing temporary lodging for those who have come from the furthest away while they await medical attention. One Heart Worldwide, one of our partner charities on this trip, is responsible for developing the newest of these, a “maternity waiting home” designed to house those families and expectant mothers who must travel especially long distances for care.
Once we reach the ultrasound room it becomes clear that ultrasound is in high demand here: the room itself and hallway outside are stuffed with expectant mothers anxiously waiting to be scanned.
We are treated to a serendipitous greeting from an SBA participant from the NYAGI Team 1 Nepal trip in September of 2016. Welcoming us to the clinic with a big smile, she proudly demonstrates her ultrasound skills to the new team.
The team briefly peeks into the the labor and delivery room, emergency room, pharmacy before funneling into a small break room. There, the doctors briefly describe their work and answer our questions. Working three eight-hour shifts to provide round-the-clock care, seven days a week, the clinic is staffed by a team of just three doctors. They explain the challenges of maternal care in a remote clinic, how they deal with difficult births, and the value of ultrasound. Their hard work is paying off: a sheet on the wall boasts zero maternal deaths in almost three years.
After thanking the doctors for their time, the team piles back into the off-road vehicles for our hot, bumpy ride back to Dhulikhel. Our side trip to Melamchi has provided the team with a slight taste of rural Nepal and its medical challenges. It’s difficult to imagine just how exhausting a five to seven day journey from the rural mountains – during the third trimester with impending labor, no less – must be when it’s arduous enough as a two hour trip by air-conditioned SUV.
Course Day 1
Monday, June 5th, 2017
Just a quick fifteen-minute walk away from the hotel, Dhulikhel Hospital is the location of the ultrasound course and where the team will finally be meeting the program’s thirty Nepali students. To our surprise, we are greeted at the entrance by a large banner announcing Dhulikhel Hospital’s Basic Ultrasound Course in OB for Skilled Birth Attendants, a joint partnership with NYAGI Project and One Heart Worldwide.
Our base of operations for the next five days of intensive training is the Women’s Health building, which has been an ongoing construction project for years. On the first NYAGI trip to Nepal, Team 1 learned that this is by no means uncommon in Nepal: buildings are frequently completed sporadically as the funds are available, so construction is often a lengthy, continuous process. Given that there is little waiting room inside, families sit outside on thin plastic mats, usually in the hot sun, while they wait for care or for news from the delivery room upstairs.
Once settled into the classroom, the team is introduced to the students, thirty wonderful SBAs – skilled birth attendants – who have traveled from regions all throughout Nepal to participate in the program. Some took five days to get here, making our journey from the States seem easy by comparison. Following a brief ceremonial greeting from representatives of the OB/GYN department and Dhulikhel Hospital, the course itself officially begins.
After a short lecture detailing the basics of setting up and taking a suitable ultrasound photo, we break into smaller groups. Each one is designed to be a cooperative, cohesive learning unit focused on a NYAGI team member’s demonstrations of ultrasound techniques and obNAV software instruction.
Students cluster tightly around each bed as the NYAGI sonographers begin walkthroughs of proper ultrasound scanning techniques. Outside the training rooms, a flock of colorfully clad pregnant women wait patiently to be scanned while within small, handheld wireless ultrasound machines and tablets are distributed between the two clinical teaching rooms.
Translators bounce rapidly from bed to bed. Fueled by necessity and a shared desire to communicate, the team and the SBAs cobble together their own surprisingly effective language comprised of hand signals and broken English. Teaching can continue even in the absence of a translator.
Enthusiastic teamwork between the NYAGI team, the incredibly motivated SBA students, the Dhulikhel Hospital staff, and One Heart Worldwide assistants is what allows us to bridge the gap between cultures and languages.
The theme of the day appears to be adaptation and flexibility. Even a leaky water pipe flooding the hallway forcing a move further down the hall, delayed display of scanning images on the tablet computers from the probes, and iPads plagued by an overload of excess files aren’t enough to dim our smiles, NYAGI and Nepali alike.
Course Day 2
Tuesday, June 6th, 2017
Beginning with a shower of much-anticipated rain, the second day marks the beginning of ultrasound obstetrics training via obNAV. The team lugs the thirty iPads – generously donated by large companies in both Colorado and California – which have been preloaded with the obNAV software.
Today the goal is to use the iPads not only to teach ultrasound but also to improve technology skills. As the day progresses – a whirlwind of activity scanning patients and attending two lectures – many of the students demonstrate increased confidence and comfort using the iPads, ultrasound probes, and obNAV software. Just like yesterday, there are hiccups for the team and SBA participants to adapt to, kinks to smooth out, and to motivation to muster to keep moving forward. After all, there is still much to learn in the remaining three days!
Following initial patient scanning, the students further develop their ultrasound skills by practicing gynecological scans on themselves.
Determinedly seeking out anatomic structures, the students learn to distinguish ultrasound artifacts from useful diagnostic information, all the while further honing their ability to use and interpret the ultrasound technology itself.
The NYAGI tech and clinical support team run around providing help where needed during the hands-on scanning sessions. Sonographers teach and demonstrate ultrasound techniques tirelessly, while their SBA students zealously absorb the glut of information thrown their way. It’s thanks to the highly organized system developed by the patient coordination team that the day is able to pass so smoothly.
Course Day 3 – Day 4
Wednesday, June 7th, 2017 – Thursday, June 8th, 2017
For most of the students, the third and fourth days of the course prove to be the the transition from mild bewilderment to the beginnings of obstetric ultrasound mastery. The SBAs show repeated “lightbulb moments,” finding key anatomical structures, sliding the probe with ease, and dealing calmly with technological glitches.
One of the team’s goals was to have the participants memorize what came to be jokingly referred to as the “NYAGI Mantra.” This set of basic obstetric ultrasound steps are those most important concepts which the NYAGI team strives to drive as deeply as possible into their student’s learning centers so that, if nothing else, they remember them even after the team has gone.
It pays off. The Nepali SBAs are all able not only to remember and recite the mantra with ease, but also to actually apply that knowledge. Every student does an exceptional job, proudly identifying fetal heads, hearts, and placentas in ultrasound images, measuring the deepest pockets of amniotic fluid, moving the probes along the spine to identify major fetal anatomical structures, and using the probes to measure the femur to calculate the estimated delivery date.
Overall, the process goes very well. Patients flow from the Antenatal OB and Gyn clinic down the hall into pre-numbered holding chairs outside the scanning rooms. Scanning beds are rarely vacant for more than a few minutes before the next mother in line has gel and probe on her belly.
Fortunately, the rapid bonding and effective communication between the Dhulikhel Hospital team and NYAGI Team allows us to work together in a synchronized, streamlined fashion, which in turn makes patients and their families feel comfortable and confident in the quality of the care that they are receiving. Order arises out of the chaos of the first day. Mothers are seeing their babies’ images for the first time, via ultrasound. Most importantly, SBAs are getting much needed and appreciated hands-on probe time, which is in truth the core of the NYAGI teaching system.
Along with many normals, the occasional abnormal and normal variants help the students develop more scanning confidence. Both the SBAs and the NYAGI team get excited each time a student experiences an “AH-HA” moment. One head…wait…two heads. Two hearts beating asynchronously. It must be twins! One set with both heads down, another in “69” position as they called it – making the sonographer blush a bit at the participants’ description.
Further examples include a blighted ovum from incomplete spontaneous miscarriage, simple ovarian cysts, a low-lying IUD, a placenta that appears older than expected for the dates that will need follow-up scanning. When appropriate, aberrancies are imaged and shared with the group.
Those who were skeptics of our rapid teaching system, students and teachers alike, become believers. Even the vice chancellor of Kathmandu University gets wind of our success and asks that we help bring more ultrasound training to other departments at Dhulikhel Hospital.
By the end of Thursday, the fourth day of the course, each and every one of the SBA’s without exception can demonstrate all but the final objective of the NYAGI curriculum. The sixth objective, biometry – measuring the babies size and estimating the date accurately – still challenges some, but it is recognized as a quite sophisticated skill even in the USA.
Course Day 5: Testing
Friday, June 9th, 2017
As a team, we find that, just as we’d hoped, the fifth and final training day brings it all together. Sonographers fine-tune their students’ skills, while students teach students. Everyone scans with enthusiasm and with pride in their newly-acquired obstetric ultrasound skills.
While there may be a few who still need a bit more confidence in their skills, overall the majority of the students feel truly capable of performing basic obstetric ultrasound.
Smiles fill the room, while with grace and kindess the staff of Dhulikel Hospital and the One Heart World-Wide volunteers organize an emotional, pat-on-the-back closing ceremony. Students and teachers, Sonographers and SBAs, Nepali and Americans, all shed tears as expressions of gratitude pour out.
Our mission of taking ultrasound technology to remote regions was on point and achievable! In five days, the participants learned the basics of OB ultrasound in addition to the skills needed to use technology: iPads, probes, and obNAV software.
We hope that we have managed to demonstrate on this trip how ultrasound truly can function like a crystal ball, allowing healthcare providers to discover potentially life-threatening conditions in advance. We have much to celebrate, but still a long way to go.
Our collective challenge: to bring ultrasound to all of Nepal and beyond.
In the end, we have bonded around the concept of NYAGI. NYAGI represents that pregnant woman in remote, resource-limited areas who may die from a complicated pregnancy and delivery. Ultimately, we all work for her.
- Team Leader: Cliff Gronseth, M.D.
- Doctors: Alicia Martin-Hirsel, Jeffrey Kerr-Layton, Cliff Gronseth
- Sonographers: Arlana Franklin, Donna Sceusa
- Support Staff: Ann Dixon, Emma Houston, Liana and Halea Kerr-Layton
- Tech Support: Ariana Brand, Casey Brown, Will Dixon
- Research Team: Rajani and Kabita Ghale, (Carol Cowley in absentia)
- Photographer: Jason Houston
… and all the kind donors to the NYAGI Project!