Photos by Jason Houston
Day 1: Arrival in Nepal
Saturday, June 3rd, 2017
Despite the logistics of rounding up fifteen volunteers scattered across the United States and arriving from all different directions halfway across the world, the entire NYAGI Project’s Team manages to meet up the same place, day and time (Kathmandu Airport, Saturday, 6 pm).
Our final destination is about an hour east of Kathmandu – Dhulikhel Hospital – where we will teach ultrasound and technology skills to healthcare providers working in remote villages. We bring expertise, iPads, and portable ultrasound machines to save lives.
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. Nepal’s rough geography, dramatic climate and tenuous road system adds a level of complexity for healthcare delivery like none other. Expectant mothers in remote areas are especially at risk due to unforeseen complications of pregnancy and childbirth. Many of those tragedies can be avoided. That’s why the NYAGI Team came.
Indira personifies NYAGI. She lives is Thokarpa, Nepal, an hour walk up the steep terraced hillside and a five hour, rock strewn, washed out, rutted, switchback drive to the nearest hospital. She delivered her second child four days ago. 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 remote villages, even the best care is severely lacking basic diagnostic and preventative tools like ultrasound.
Indira’s story is similar to many mothers in Nepal who could benefit from ultrasound technology. Remote locations and the unpredictable, sometimes inaccessible roads damaged by heavy rain or landslides make access to life-saving care in the throws of childbirth extremely difficult. NYAGI’s aim is to bring ultrasound technology to resource-limited areas to help anticipate dangers of labor and delivery, to prevent needless morbidity or mortality that a pregnant woman may face in remote areas. Ultimately, we all work for her.
Our mission in Nepal is focused: teach the basics of obstetric (OB) ultrasound to a group of Skilled Birth Attendants (SBA’s) in just five days, provide them with tools and resources to continue to learn, and develop a system to communicate with them in the future. The ultrasound machines allows the SBA’s to do prenatal scanning when they return to their remote villages. The obNAV software loaded onto donated iPads allows for ongoing learning. Mobile device management software allows us to track and update the iPads, to communicate with the SBAs, and to create a bridge from iPad donor to recipient…thereby, connecting the world.
Why ultrasound? Ultrasound is ideal for use in remote areas: it’s portable, safe, and immediate. It provides dynamic, real time imaging quickly and harmlessly. Ultrasound technology can act as a modern-day crystal ball, predicting future trouble and potentially preventing death.
It’s a wonderful feeling to be able to proactively save lives with the power of ultrasound.
We’ve brought donated iPads preloaded with obNAV software – an 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.
Teaching the SBA’s about the 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. Our team, comprised of sonography experts and tech-savvy high school and college students, have to teach not just what to look for, but also how to look for it.
Before the training course at Dhulikhel Hospital officially begins, the team takes a “road trip” to a rural clinic. Despite the relatively short distance, roughly twenty miles from Dhulikhel, the journey to Melamchi takes almost three hours on winding, washed-out, pedestrian-filled roads that would challenge most Western drivers. Cars, motorcycles, people, animals, trucks and busses all pass each other with finesse and respect on muddy, single-lane roads that hug the hillside. Steep cliffs define the road edge. At times, the ride can be outright frightening… but the views spectacular!
Upon arrival at the Melamchi clinic, we see an ambulance parked outside the rural clinic. Inside the ambulance lies a nineteen-year-old woman and her three-day-old newborn baby. After a four-hour trek to the Melamchi Clinic, bleeding and suffering, the new mother was examined via ultrasound and determined to need more advanced care at Dhulikhel Hospital.
Stories like this are not unusual here. During a tour of the clinic, we learn that many patients travel for hours or days – usually on foot – for examination, diagnosis and treatment. Some have appointments; 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 far away while they await medical attention. One Heart Worldwide, one of our partner charities on this trip, is responsible for developing a new “maternity waiting home” designed to house families and expectant mothers who travel especially long distances.
Once we reach the ultrasound room it becomes clear that ultrasound is in high demand in Melamchi. The hallway and the ultrasound exam room are stuffed with expectant mothers anxiously waiting to be scanned.
An SBA participant from the NYAGI Team 1 Nepal trip (September 2016) welcomes us with a big Nepali smile and proudly demonstrates her ultrasound skillset to the NYAGI Team 2.
We tour the rest of the clinic, peeking into the the labor and delivery, emergency, and pharmacy rooms before funneling into a small break room. There, the doctors describe their work and answer our questions. The clinic is staffed by a team of three doctors, each working 8-hour shifts to provide 24-hour care, seven days a week. No breaks. No vacations. 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 large data poster on the wall boasts zero maternal deaths and the latest number of referrals to regional hospitals among other things.
After thanking the doctors for their time, the team piles back into the off-road vehicles for our bumpy ride back to Dhulikhel. Our trip to Melamchi provides the team with a taste of the transport and medical challenges of rural Nepal, even though we are only 20 miles from Dhulikhel Hospital. It’s hard to imagine a five to seven day journey out of the remote villages, nine months pregnant with impending or active labor.
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 participants, thirty wonderful SBAs – Skilled Birth Attendants – who traveled from regions throughout Nepal to participate in our program. Some travelled five to seven days, 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 ultrasound, we break into smaller groups for hands-on scanning practice. Participants 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 anxiously wait to be scanned.
Enthusiastic teamwork between the NYAGI team, the SBA students, the Dhulikhel Hospital staff, and One Heart Worldwide assistants is what allows us to bridge the gap between cultures and languages.
Course Day 2
Tuesday, June 6th, 2017
The second day marks the beginning of training via obNAV software. The team distributes thirty iPads generously donated by companies for the NYAGI Project. The repurposed iPads have been preloaded with the obNAV software, specifically designed for continued learning upon the SBA’s return to their rural clinics.
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 increasing confidence and comfort using the iPads, ultrasound probes, and obNAV software. At times, the SBAs take turns scanning each other to improve their gynecological ultrasound skills.
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.
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 believe ultrasound can function like a crystal ball, predicting the future, allowing healthcare providers to identify potentially life-threatening conditions early…to see trouble before trouble begins. 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…together! 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!